Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Updated GOLD Guidelines for COPD
GOLD report; 2016 Nov 17; GOLD committee
The 2017 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy stresses the importance of individualized treatment for all patients with COPD and includes the following new revisions and recommendations:
- Assessment and regular evaluation of inhaler technique has been added to attempt to improve therapeutic outcomes.
- Examination of symptoms and future risk of exacerbations should provide the map for pharmacologic management of stable COPD.
- Patients with persistent symptoms should be started on a long-acting bronchodilator (a LABA or a LAMA), and if symptoms persist, then dual bronchodilator therapy should be added.
- For patients with symptoms on a long-acting bronchodilator, advancement to dual-bronchodilator therapy is preferred over the combination of an inhaled-corticosteroid and a long-acting bronchodilator.
- A shift toward a more personalized approach to treatment is discussed, with strategies for escalation and de-escalation of pharmacotherapy.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). GOLD 2017 global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease, 2017 report. November 17, 2016. http://goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/. Accessed November 27, 2016.
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The GOLD guidelines are the standard international guidelines for treatment of COPD and are updated on an annual basis. They recommend an approach to COPD where we assess both symptoms and risk for future exacerbations. Both degree of decrement in FEV-1 and a history of past exacerbations influence the risk of future exacerbations. For patients with only occasional symptoms, a short acting bronchodilator, either a short-acting beta-agonist or a short-acting muscarinic antagonist is recommended. For patients with persistent symptoms, either a long-acting beta-agonist (LABA) or a long-acting muscarinic antagonist (LAMA) is recommended. For patients with persistent symptoms on single bronchodilator therapy, advancement to dual therapy with a LAMA plus a LABA, or combination ICS/LABA is recommended, with a preference given to dual-bronchodilator therapy. Dual bronchodilator therapy is given preference based on the increased risk of pneumonia with the use of ICS in patients with COPD and the superior efficacy in preventing exacerbations and improving patient reported outcomes in the most severe category of patients with COPD when dual bronchodilator therapy is compared to ICS/LABA therapy. For the most severe category of patients, triple therapy with LAMA/LABA/ICS can be used, with the addition of roflumilast if FEV-1 is less than 50% and patient has chronic bronchitis. —Neil Skolnik, MD