COPD’s Old Narrative Is Outdated, GOLD Leaders Say in 2027 Update

During a presentation on the updates to the 2027 Global Initiative for Chronic Obstructive Lung Disease (GOLD) report, presenters called the traditional smoking-centered story of chronic obstructive pulmonary disease (COPD) outdated. In addition, nonpharmacological care, including pulmonary rehabilitation, is a core part of the 2027 GOLD report.

The report also adds a new section with the Global Initiative for Asthma¹; updates definitions for early, mild, young-person, and pre-COPD; revises sections on CT and cardiovascular disease; and changes the initial treatment recommendation for group A to a long-acting muscarinic antagonist (LAMA), its only change to drug recommendations. The full report will be released on World COPD Day, November 18, 2026.

What Changed in GOLD 2027

Claus Vogelmeier, MD, chair of the GOLD Science Committee and a professor of medicine at Philipps University of Marburg in Germany, said nonpharmacological treatments are complementary to drug therapy and together form comprehensive management of COPD.

“One without the other is useless, and unfortunately, non-pharmacological management is neglected and more or less not done in most individuals with the disease,” he said.

The revised guide also recommends evaluating patients in group B, who have not experienced exacerbations but are breathless walking flat surfaces, for pulmonary rehabilitation at diagnosis along with patients in group E, who have had exacerbations. Instead, only a small number of patients undergo pulmonary rehab, Vogelmeier said. He added that the current pharmacological management of patients with COPD in exacerbation is “really bad medicine.”

The only change to drug recommendations in the report was to shift patients in group A to a LAMA based on the results of a systematic analysis, including a Chinese trial of about 800 patients with mild to moderate disease who received tiotropium or placebo.²

“In the new document, we propose to use a LAMA in newly diagnosed individuals that fulfill the criteria for GOLD A,” Vogelmeier said.

In the United States, the least expensive LAMA costs about $80 without insurance, and the cost of these drugs was discussed by the committee, and it did realize that the drug class is out of reach in some countries, he said. “In an ideal world, I think the evidence is good enough now to make the recommendation to give a long-acting bronchodilator, and in particular LAMA,” he said.

The 2027 report also provides new definitions for early COPD, mild COPD, and COPD in young individuals. Early COPD shouldn’t be used to describe patients in clinical settings, and mild COPD should only describe airflow limitation severity. Young people are defined as those younger than 50 years, something discussed in the following presentation about rethinking the traditional definitions of the disease.

The CT section now covers mucus plugging, which has been tied to higher mortality in the COPDGene cohort.³ Vogelmeier called mucus plugging a new frontier” for COPD treatment. In the tozorakimab trials, presented at the European Respiratory Society, scans before and after treatment in about 700 patients showed a dose-dependent reduction in plugs.⁴

“We do not know right now what this implies regarding clinical end points, but at least it shows that we can do something about that,” he said.

Why the COPD Narrative Must Change

Àlvar Agustí, MD, PhD, chair of the GOLD Board of Directors and a professor of medicine at the University of Barcelona, said the committee considers the prevailing story of COPD outdated and presented a call to action that updates the narrative.

“The old narrative is that COPD was a self-inflicted disease by smoking occurring in all males and characterized by rapid decline of lung function. This is what we learned many years ago in medical school,” he said.

Smoking remains the main risk factor, he said, but infections, prematurity, low birth weight, and low socioeconomic status also contribute, and COPD occurs in women and young people. A small proportion of the population may also never develop the lungs properly in infancy and adolescence. These people have more comorbidities, die earlier, and are left out of trials because they are diagnosed too late, he said.

Diagnosis is the central gap that needs to improve to start management earlier and even personalize it.

“Poor diagnosis, late diagnosis, wrong diagnosis,” Agustí said. “This is a huge public health problem, and we need to consider that in any call to action.”

The call to action also prioritizes prevention beyond smoking, earlier and more personalized management, attention to comorbidities beyond the lung, and exacerbations. However, he said there is still a lot unknown about exacerbations.

Echoing what Vogelmeier said about young patients, Agustí pointed out that trial participants are typically 68 years old, and data on treating younger patients are lacking. He also raised cure as a goal when patients are diagnosed and treated earlier.

“I personally think that if we continue diagnosing COPD at the age of 70, we will never cure COPD,” he said. But if earlier diagnoses catch patients in the 40s or 30s, then there is a possibility of curing or getting the disease into remission.

Ultimately, he stressed that the call to action, which is under review to publish with the American Journal of Respiratory and Critical Care Medicine, is not a guideline, which would present evidence.

“This is an aspirational document, which probably is incomplete, probably wrong, but we think at the science committee in GOLD that it is about time to reconsider a new narrative and a call to action for COPD patients,” Agustí said.

References

1. Halpin DMG, Masekela R, Vogelmeier CF, et al. Addressing the global challenges of COPD and asthma: a shared vision from GOLD and GINA. Am J Respir Crit Care Med. 2026;212(2):297-302. doi:10.1164/rccm.202508-1894PP
2. Zhou Y, Zhong NS, Li X, et al. Tiotropium in early-stage chronic obstructive pulmonary disease. N Engl J Med. 2017;377(10):923-935. doi:10.1056/NEJMoa1700228
3. Diaz AA, Orejas JL, Grumley S, et al. Airway-occluding mucus plugs and mortality in patients with COPD. JAMA. 2023;329(21):1832-1839. doi:10.1001/jama.2023.2065
4. Washko G, Sciurba F, Watz H, et al. Tozorakimab reduces the number of lung segments with mucus plugs in patients with COPD at high risk of exacerbations: integrated analysis of the replicate OBERON and TITANIA phase 3 studies [late-breaking abstract]. Presented at: ERS Congress 2026; September 5-9, 2026; Barcelona, Spain. Abstract 131612.