How the GOLD 2026 Guidelines Updated COPD Diagnosis and Treatment

The biggest gains in chronic obstructive pulmonary disease (COPD) management still come from low-cost basics like smoking cessation, vaccination against infections, and exercise, explained Shawn Aaron, MD, senior scientist in inflammation and chronic disease at Ottawa Hospital Research Institute and professor of the Division of Respirology at the University of Ottawa, during a preconference session at the 2026 GOLD International COPD Conference.¹

Aaron and Corinne Young, MSN, FNP, FCCP, a nurse practitioner at Colorado Springs Pulmonary Associates and president and founder of the Association of Pulmonary Advanced Practice Providers, opened the conference by discussing how to apply the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines at diagnosis and initial treatment. They highlighted what the 2026 GOLD guidelines reinforce and what was updated.

GOLD is a nonprofit created in 1997 by the National Heart, Lung, and Blood Institute and the World Health Organization to raise awareness, diagnosis, and treatment of COPD.

How GOLD 2026 Changed COPD Diagnosis and Grouping

Young stressed that diagnosis is not just about a test result but is also about the symptoms that the patient is experiencing.

“We don’t want to look at just numbers when we’re thinking about our COPD patients,” she said. Patients typically have cough, sputum production, shortness of breath, or some combination, she said, along with an exposure history.

Tobacco remains a common cause in the US, but Young cautioned against fixating on a 10-pack-year threshold. The Copenhagen City Heart Study for COPD challenged that traditional threshold, finding that about a quarter of patients smoked less than that.² She also said exposures vary by region.

“When I worked in California, I never saw miners. When I moved to Colorado, I now see mining patients and have to learn about mining lung diseases,” Young said.

Spirometry still anchors diagnosis, with a fixed forced expiratory volume in 1 second (FEV₁) and forced vital capacity (FVC) ratio of 0.7 or less indicating obstruction when paired with symptoms and exposures, according to the 2026 GOLD report.³ GOLD has declined to follow the American Thoracic Society and European Respiratory Society toward lower limits of normal and z-scores. GOLD only allows clinicians to consider z-scores for patients younger than 50 years or patients of very advanced age, who could be missed by the fixed cutoff.

“The reason why [GOLD is] stuck on a fixed ratio is that this historically has been used in any FDA trial for any obstructive lung disease therapy that we’re using,” Young said.

Young also described patients who fall outside the diagnosis. Patients with pre-COPD have symptoms and exposures but no obstruction on the ratio, while those with preserved ratio impaired spirometry, known as PRISm, have an abnormal FEV₁ with a normal FEV₁/FVC ratio.

“About a third of these patients or more can develop COPD as time goes on,” she said. “We don’t really have a great pathway for them as far as what we do long term.”

The biggest GOLD change for 2026 is the threshold for the highest-risk group, group E, which dropped from 2 or more exacerbations in the prior 12 months to only 1 or more.

“Our goal is zero exacerbations in these patients, and if they are not there, we are moving them into a different category and therapy,” Young said. Approximately 20% of patients who experience a severe exacerbation that requires a hospitalization are dead within a year, she said, which explains the urgency. In the A, B, and E scheme, group A has few symptoms and no exacerbations, group B has high symptom burden and no exacerbations, and E is any patient with an exacerbation.

Other changes from 2025 include shifting screening from the general population toward symptomatic people with concerning exposures and considering CT scans for patients in diagnostic gray areas.

In audience questions, Young said moderate exacerbations deserve more attention. “Moderate exacerbations are what oftentimes are most underreported, right? Some patients will not seek any treatment for a moderate exacerbation and just kind of tough their way through it,” she said. “We’re just going to play fireman and treat them as they come in, and we want to be more of Smokey the Bear and try to prevent them from happening.”

Why Nonpharmacologic Care Comes First in COPD

Aaron framed treatment goals as easing symptoms and lowering risk, which works toward increasing patient survival. But he argued during COPD management that drugs come second to smoking cessation, vaccination, and exercise.

“COPD management starts with nonpharmacologic intervention,” he said. “As doctors, we’re very keen, obviously, to pull out our prescription pad and start prescribing medicines, but you can get a lot more bang for your buck with these 3 interventions than you can with drugs,” Aaron said.

He pointed to the Lung Health Study, in which patients with mild COPD who quit smoking improved lung function and slowed their decline.⁴ Although COPD is not curable, Aaron said that a patient with mild COPD who quits smoking can basically be cured of their COPD.

“This is the intervention you will do that will help more of your patients than any others,” he said.

In terms of cost, smoking cessation delivers more benefit per dollar than prescribing expensive biologics, Aaron said. He recommended the “ask, advise, assess, assist, arrange” approach, with positive reinforcement at each visit.

“The worst thing you can do as a clinician is to make someone feel bad about their bad habits, because that will not get them to quit,” Aaron said.

Vaccination was his second pillar because 40% to 60% of COPD exacerbations are associated with respiratory tract infections.⁵ Aaron recommends pneumococcal conjugate (Prevnar 20 or 21), respiratory syncytial virus for patients 50 years and older, and yearly influenza and COVID-19 shots.

On exercise, Aaron advises aerobic and strength training for 30 minutes 4 times a week, and pulmonary rehab for patients with significant breathlessness.

“I don’t care how bad your lung disease is. If you sit on the couch, you will get worse,” he said.

When Triple Therapy Replaces Dual Therapy

For treatment-naive patients, Aaron said, group A starts on a long-acting muscarinic antagonist (LAMA), group B starts on a LAMA plus a long-acting ß-agonist (LABA), and group E also starts on LABA-LAMA, or on triple therapy with an inhaled corticosteroid (ICS) if blood eosinophils are 300 (cells/mcL) or higher.

He said technique with the inhaler matters as much as the drug. “I do not let anyone leave my office with an inhaler until I have shown them myself how to use it,” Aaron said. “People can nod and say, ‘Oh yeah, I understand, I understand,’ and then you watch them do it, and they didn’t get it at all.”

“I get them on the LABA-LAMA. If they have an exacerbation in the next year on the LABA-LAMA, I put them on triple therapy. GOLD says only use triple therapy if the eosinophil count is 100 or greater. I don’t care what the eosinophil count is. I get them all on triple therapy because it’s really not going to hurt them.”

If exacerbations continue, Aaron puts them right on a triple therapy regardless of what the eosinophil count is, because he feels it won’t really hurt the patient. Even though roflumilast (Daliresp; AstraZeneca) is listed as an option for these patients whose exacerbations continue, Aaron avoids it, citing poor tolerability, and instead considers azithromycin, particularly in former smokers, or the biologic dupilumab (Dupixent; Sanofi and Regeneron) for patients with chronic bronchitis and elevated eosinophils. In the future, tozorakimab is expected to be available, with a Prescription User Drug Fee Act target action date in the first quarter of 2027.

His case for triple therapy draws on the IMPACT (NCT02164513) and ETHOS (NCT02465567) trials, which show triple therapy saves lives and reduces the risk of exacerbations.^7,8

“If you treat 83 patients with a triple therapy instead of a LABA-LAMA, you can prevent 1 death over 1 year. That’s a mortality signal that actually is important,” Aaron said.

References

1. Aaron S, Bizik B, Criner G, Young C. GOLD 2026 pre-conference session: diagnosis and initial treatment. Presented at: GOLD International COPD Conference; November 5-6, 2026; Philadelphia, Pennsylvania.
2. Çolak Y, Løkke A, Marott JL, et al. Low smoking exposure and development and prognosis of COPD over four decades: a population-based cohort study. Eur Respir J. 2024;64(3):2400314. doi:10.1183/13993003.00314-2024
3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of COPD: 2026 Report. 2026. https://goldcopd.org
4. Scanlon PD, Connett JE, Waller LA, et al; Lung Health Study Research Group. Smoking cessation and lung function in mild-to-moderate chronic obstructive pulmonary disease. The Lung Health Study. Am J Respir Crit Care Med. 2000;161(2 Pt 1):381-390. doi:10.1164/ajrccm.161.2.9901044
5. Traves SL, Proud D. Viral-associated exacerbations of asthma and COPD. Curr Opin Pharmacol. 2007;7(3):252-258. doi:10.1016/j.coph.2006.11.010
6. Tozorakimab demonstrated statistically significant and highly clinically meaningful reduction in COPD exacerbations in OBERON and TITANIA phase III trials. News release. AstraZeneca. September 8, 2026. Accessed November 5, 2026. https://www.astrazeneca.com/media-centre/press-releases/2026/tozorakimab-demonstrated-statistically-significant-highly-clinically-meaningful-reduction-copd-exacerbations-oberon-titania-phase-iii-trials.html
7. Lipson DA, Barnhart F, Brealey N, et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med. 2018;378(18):1671-1680. doi:10.1056/NEJMoa1713901
8. Martinez FJ, Rabe KF, Ferguson GT, et al. Reduced all-cause mortality in the ETHOS trial of budesonide/glycopyrrolate/formoterol for COPD. Am J Respir Crit Care Med. 2021;203(5):553-564. doi:10.1164/rccm.202006-2618OC