COPD Stakeholder Summit: Utilizing Peak Inspiratory Flow Rates to Individualize Treatment and Improve Outcomes - Episode 6
Recommendations to clinicians who refer to and utilize the GOLD criteria to best treat patients with chronic obstructive pulmonary disease.
Neil Minkoff, MD: Dr Mahler, you mentioned the GOLD [Global Initiative for Chronic Obstructive Lung Disease] guidelines earlier. We’ve been at this for over 20 minutes now, so maybe it’s time to re-engage with the GOLD guidelines, which I think we were all taught as the standard of care or at least something that helps drive our decision-making. Could you talk a little bit about the COPD [chronic obstructive pulmonary disease] management style based on the GOLD guidelines and how you translate those into inhaler use and techniques?
Donald A. Mahler, MD:Let’s start with the acronym GOLD. It refers to the Global Initiative for Chronic Obstructive Lung Disease. This is a group of global experts on COPD, which includes a lot of researchers who have generated some of the seminal studies on understanding and treating COPD. Each year, they come up with recommendations, which they call strategies. They update the approach based on published studies in the past year. The basic paradigm is that once COPD is diagnosed, it’s categorized into 1 of 4 different quadrants or groups, labeled A, B, C, and D. Groups A and B have a reduced risk of an exacerbation based on past history of exacerbations. Groups B and D represent increased symptoms, shortness of breath, and/or other respiratory symptoms.
Without going into more detail, that summarizes the groupings. As Brad mentioned, medication and delivery system are equally important. The GOLD document focuses more on medications and less on delivery systems. I think that’s in part because there are far more studies that have looked at molecules and far fewer that have looked at inhaler selection.
When you interact with a patient, the first step of the GOLD recommended management cycle is toreview his or her status—how they’re doing— then assess their inhaler technique and adherence to medication. If they’re doing well, continue what you’re doing. If they’re not doing well, then you might adjust the molecule, the delivery system, or both. It’s a continuous cycle of review, assess, and adjust at each visit. That summarizes the approach. If people aren’t doing well, you might escalate or increase use of one of the medications. You may change the delivery system. If they’re doing very well, there is an option for de-escalating therapy, which mainly relates to consideration of withdrawal of inhaled corticosteroids.
This activity is supported by an educational grant from Boehringer Ingelheim.