COPD Disease Stability Emerges as a Treatment Target in GOLD 2026

Disease stability, defined as no exacerbations, no worsening symptoms, and no lung function decline beyond normal aging, is emerging as the benchmark for judging chronic obstructive pulmonary disease (COPD) treatment. Advancing therapy when patients fall short of it should be routine rather than a last resort, according to speakers at a pre-conference session of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) International COPD Conference.

David Singh, MBBChir, MA (Cantab), MRCP, MD, FBPhS, FERS, professor of clinical pharmacology and respiratory medicine and medical director in the Medicines Evaluation Unit at the University of Manchester; Corinne Young, MSN, FNP, FCCP, nurse practitioner at Colorado Springs Pulmonary Associates and president and founder of the Association of Pulmonary Advance Practice Providers (APAPP); and Brian Bizik, MS, PA-C, DFAAPA, clinical supervisor and asthma, allergy, and COPD care coordinator at Terry Reilly Health Centers and cochair of the COPD committee of the APAPP, walked attendees through disease stability, exacerbations, and dyspnea in the 2026 GOLD report.¹

Why Disease Stability Is Now a COPD Treatment Target

The GOLD report now gives clinicians a concrete goal to achieve disease stability, which is a target other chronic inflammatory diseases already had, said Singh. He defined stability as a state of low disease activity where the patient has no exacerbations, and their symptoms may even improve over time.

“Disease stability is a phrase that a couple of years ago we weren’t using,” Singh said. “It’s in the GOLD report now, and I’m very pleased that it seems to be taken more and more into clinical practice.”

Post hoc trial data suggest the target is attainable but population dependent. In the IMPACT trial, 22% of patients with an exacerbation history on triple therapy were stable over a year, compared with 46% in the lower-risk FULFIL trial.^2,3 Among the exacerbation-free patients, 37% improved their COPD Assessment Test (CAT) score by more than 4 points, he said. Patients stable at week 28 had a 51.7% lower risk of all-cause mortality afterward in a published analysis.

Using a 2-component measure of exacerbations and no worsening of symptoms is easy, but Singh advocates for measuring disease stability based on 3 components, which would add conducting spirometry on a yearly basis to determine lung function isn’t worsening.

“I think [the] 3-component [composite] is more robust, and then that enables you to better identify the patients who require a review of their management,” Singh said. “I would look carefully at the components that they are not meeting stability on, because that will enable you to decide the type of optimization the patient needs.”

How the Dyspnea Pathway Guides Treatment Escalation

Young focused on patients whose main problem is breathlessness, or dyspnea, one of the main reasons patients see a specialist. In the GOLD report there is not only an exacerbation pathway to follow but also one for dyspnea without exacerbations. If a patient does have an exacerbation, Young said that’s the pathway to start with.

For GOLD group B patients, who haven’t had an exacerbation but get breathless easily, dual long-acting bronchodilator therapy is recommended upfront, supported by randomized trials showing better lung function, breathlessness, and health status than monotherapy. The GOLD guideline does not ignore that some patients may experience access or cost issues, Young noted.

“[GOLD does] recognize that monotherapy may be the only therapy that patients can get access to, and that may be just what we are able to give them,” she noted.

For patients who remain breathless on optimized dual therapy, Young said evidence is thin for adding an (ICS) corticosteroid unless asthma overlaps. Instead, Young suggests talking to patients about non-pharmacological options to improve their dyspnea. Ensifentrine (Ohtuvayre; Verona Pharma), a nebulized add-on, is now an option, and data show it improves dyspnea.^4,5 Although she said it would not be used in place of an inhaler the patient was currently on, which patients sometimes assume.

Pulmonary rehabilitation belongs at every GOLD stage, she said, with most Medicare programs paying for up to 12 weeks. Access remains a barrier: Medicare data show roughly two-fifths of adults with COPD, and 8 in 9 in rural areas, have poor access to rehabilitation centers.⁶ Since many of her patients didn’t or couldn’t drive but wanted to go to pulmonary rehab, Young used to try and get pulmonary rehab grant funding for a bus. Virtual programs also help, and once her state approved that program, they started sending more referrals to it.

For refractory patients, the strongest evidence for reducing dyspnea is opioids, which palliative care teams may prescribe. Acupuncture and acupressure have also made it to the GOLD recommendations and may help patients with advanced disease.

Overall, it’s important to realize that patients with dyspnea are treated on a different pathway than those with exacerbations with dual therapy upfront and no ICS unless there is an overlapping asthma diagnosis.

“Optimize before you escalate, so don’t assume they’re taking their therapies appropriately,” Young said. “[You] definitely want to double-check.”

When Exacerbations Warrant Advanced Therapy

Bizik addressed the exacerbation pathway, saying a group of family physicians he recently spoke with viewed its final tier as only for the sickest patients, which he felt was inaccurate. “This isn’t a last resort. This is just the next step,” he said.

He urged clinicians to change nothing when patients are doing well, noting that there is data that suggests about half of patients may be struggling and need to advance while the other half are fine where they are. Patients on dual bronchodilators with initial eosinophils above 300 cells/µL move to triple therapy; if technique checks out and they still experience exacerbations, triple therapy can be considered above 100 cells/µL.

For patients still exacerbating on appropriate triple therapy, GOLD lists 4 options: roflumilast (Daliresp; AztraZeneca), long-term azithromycin, and 2 biologics, dupilumab (Dupixent; Sanofi and Regeneron) and mepolizumab (Nucala; GSK). Azithromycin works best in former smokers, Bizik said, but requires monitoring for QT prolongation, hearing loss, and tinnitus.

Bizik sought to ease hesitancy about biologics, but the ones in the GOLD guideline are not immunosuppressive like rheumatologic drugs. Clinicians uncomfortable prescribing them should refer their patients.

“…our job is to get them to the right person because this makes sense for our patients and this can impact their disease control and severity,” he said. “I just want to encourage you that this is a pathway that works for patients, and continue moving down or enlist the help of somebody who can help you get there.”

References

1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD: 2026 Report. Accessed November 5, 2026. https://goldcopd.org/2026-gold-report-and-pocket-guide/
2. Singh D, Stacey R, Halpin DMG, et al. Defining disease stability in chronic obstructive pulmonary disease: evidence from phase 3 clinical trials. Am J Respir Crit Care Med. 2026;212(9):2036-2049. doi:10.1093/ajrccm/aamag292
3. Lipson DA, Barnacle H, Bink R, et al. FULFIL trial: once-daily triple therapy for patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 2017;196(4):438-446. doi:10.1164/rccm.201703-0449OC
4. McCormick B. FDA approves ensifentrine for maintenance treatment of adult patients with COPD. AJMC®. June 26, 2024. https://www.ajmc.com/view/fda-approves-ensifentrine-for-maintenance-treatment-of-adult-patients-with-copd
5. Mahler DA, Bhatt SP, Rheault T, et al. Effect of ensifentrine on dyspnea in patients with moderate-to-severe chronic obstructive pulmonary disease: pooled analysis of the ENHANCE trials. Expert Rev Respir Med . 2024 Aug;18(8):645-654. doi: 10.1080/17476348.2024.2389960
6. Malla G, Bodduluri S, Sthanam V, Sharma G, Bhatt SP. Access to pulmonary rehabilitation among Medicare beneficiaries with chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2023;20(4):516-522. doi:10.1513/AnnalsATS.202204-318OC