Updates in COPD: The 2019 GOLD Guidelines
Sara Massey, Pharm.D., Smiley’s Family Medicine Clinic
Background: Chronic obstructive pulmonary disease (COPD) is a preventable and manageable disease currently ranked as the 4th leading cause of death worldwide according to the 2019 Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Risk factors for developing COPD include smoking tobacco, biomass fuel exposure, and air pollution. Each year, GOLD releases an updated summary highlighting diagnostic criteria and treatment guidelines for the management of COPD. Three main areas were updated in the 2019 guidelines: 1) simplification of treatment options, 2) use of the ABCD assessment, and 3) incorporation of management cycles.
Evidence: The updated guidelines continue to recommend the utilization of the ABCD assessment tool for the initial treatment of COPD, but no longer recommend its use to adjust treatment thereafter. This tool is used to direct pharmacological treatment based on a patient’s modified Medical Research Council (mMRC) dyspnea scale or COPD Assessment Test (CAT) score and the number of exacerbations leading to hospitalizations. When comparing the 2018 and 2019 GOLD guidelines, the initial treatments for Groups A, B, C, and D are similar with the exception that the 2019 guidelines do not include the preferred treatment algorithm. The initial treatment is now streamlined: Group A) bronchodilator; Group B) LABA or LAMA (there is evidence monotherapy is sufficient at symptom control and combination therapy is not twice as effective); Group C) LAMA; Group D) LAMA, LABA + LAMA (in addition to symptoms and CAT >20), or ICS + LABA (depending on specific lab values).
Additionally, the 2019 update focuses on using the ABCD assessment to determine initial treatment only and then utilizing the management cycle to follow-up and make changes to treatment. The management cycle involves a three step process: review, assess, and adjust, designed to treat COPD based on symptoms and exacerbations. Recommendations at follow-up are no longer dependent on the patient’s GOLD group (A, B, C, D) at diagnosis.
Another update includes new evidence to incorporate the use of peripheral blood eosinophil counts (EOS) to estimate the efficacy of inhaled corticosteroids (ICS) for exacerbation prevention. The use of ICS is no longer recommended in Group C for initial therapy and the use of an ICS for initial therapy is based on if a patient falls into Group D and has an EOS count ≥ 300 cells/µL. The use of ICS at follow-up is determined based on symptoms of dyspnea and exacerbations. Therapies can be escalated or de-escalated based on specific medication-related factors or symptom control.
The guideline recommended three steps be conducted at each visit to ensure appropriate management of COPD. At each visit, a provider should review symptoms, assess inhaler technique, adherence and non-pharmacological approaches (such as smoking cessation, pulmonary rehabilitation, exercise training, etc.), and adjust medications if needed. If a patient’s current treatment achieves treatment goals, no changes in treatment are recommended during assessment. If the treatment is not optimized, consider therapy changes based on separate dyspnea and exacerbation algorithms. If a patient presents with both dyspnea and an exacerbation, the exacerbation algorithm should be used.
Discussion and Clinical Impact: The majority of the recommendations involving diagnosis remained the same as previous updates. An ICS is no longer recommended in GOLD Group C for initial therapy. ICS are only recommended for initial treatment in patients that fall into Group D with elevated EOS. Additionally, the guideline highlighted a follow-up management guide to better manage patients with COPD. Guidelines no longer recommend using mMRC or CAT scores directly to manage treatment options after initiating therapy, but symptom assessment at each visit is important to determine if therapy changes are necessary. Clinically, it is important to treat each patient as an individual, follow the new highlighted treatment algorithms, and utilize the management cycle during follow-up.
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2019 report. https://goldcopd.org/wp-content/uploads/2018/11/GOLD-2019-v1.7-FINAL-14N.... Accessed January 24, 2019.
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2018 report. https://goldcopd.org/wp-content/uploads/2017/11/GOLD-2018-v6.0-FINAL-rev.... Accessed January 24, 2019.