GOLD's COPD Escalation Rule Draws Debate: Francesca Polverino, MD, PhD

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The Global Initiative for Chronic Obstructive Lung Disease (GOLD) suggests escalating treatment in patients with chronic obstructive pulmonary disease (COPD) after just 1 moderate exacerbation. Yet this suggestion is highly debated among clinicians in the respiratory community.

It was also one of the key topics for debate during the session on treatment escalation in patients with COPD at the European Respiratory Society (ERS) 2026 International Congress in Barcelona, Spain. Because the severity of an exacerbation has yet to be defined across research and clinical practice, it makes it difficult to determine what is severe or moderate and therefore warrants escalation, Francesca Polverino, MD, PhD, a physician scientist and tenured Lester and Sue Smith Professor of Medicine at Baylor College of Medicine, and a speaker at the ERS congress, said in an interview with The American Journal of Managed Care^®.

Working in a county hospital, Polverino treats a lot of underserved populations, and the majority of her patients are either uninsured or on Medicare or Medicaid. This makes assessing exacerbations difficult because they often occur in an outpatient setting, such as a primary care physician's (PCP) office.

“How do we call this exacerbation if it's not even recorded in the ER [emergency room]?” she said. “This is the first thing that we should have clarity on. We should get a better definition of moderate versus severe exacerbation because I think we're not there yet.”

But from an immunological standpoint, Polverino explained, a patient's underlying lung condition is more important than exacerbation severity. When used to measure airflow obstruction, patients categorized as GOLD 3 or 4 have limited options regarding anti-inflammatory treatments.

“When you get to GOLD 3 and GOLD 4, the lung tissue is really not in a good shape to respond to anything,” she said.

Once patients are categorized as GOLD 3 or 4, Polverino said, the lung tissue is too damaged to consider anti-inflammatory options, because current biologics are unable to significantly change forced expiratory volume in 1 second at that stage.