Megan Traxler, PharmD, Allina Health
Background: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) published their 2023 guideline update for chronic obstructive pulmonary disease (COPD) management in November 2022. This annual update focuses on changes to definitions, diagnosis, and management of COPD.
Evidence and Discussion: The definition of COPD has been updated to focus more on the diverse nature of COPD and states,“COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/ or alveoli (emphysema) that causes persistent, often progressive airflow obstruction.”
To differentiate between an acute exacerbation and disease progression, the definition of exacerbation was updated to be more inclusive regarding signs and symptoms. These include increased dyspnea, cough, and sputum production with a time frame reference of symptom worsening in less than 14 days.
The ABCD Assessment tool has been updated to the ABE Assessment tool, combining Groups C and D into Group E due to clinical irrelevance of Group C. The new ABE Assessment tool also focuses on exacerbation history. Additionally, pharmacotherapy recommendations have been updated to state that those in Groups B and E should be started on a combination of LABA (Long Acting Beta 2 Agonist) and LAMA (Long Acting Muscarinic Antagonist) therapy instead of either alone. The use of LABA/ICS (Inhaled Corticosteroid) has been phased out given the superiority and all-cause mortality reduction of triple therapy with LABA/LAMA/ICS when corticosteroids are indicated. The removal of LABA/ICS inhalers from COPD recommendations is more in line with current evidence that corticosteroids are most effective when eosinophilic inflammation is present. Triple therapy is recommended if the patient has a blood eosinophil count of 300 cells/µL or greater, concomitant asthma, or 2 or more exacerbations in a year. If the patient falls into Group B category with blood eosinophil count between 100-300 cells/µL, consider the patient's individual risk/benefit of ICS treatment in the shared decision-making process. ICS use is not recommended if the patient has had multiple pneumonia events, a blood eosinophil count <100 cells/µL, or a history of mycobacterial infections.
The importance of non-pharmacological interventions to reduce mortality is emphasized in this update and includes smoking cessation, pulmonary rehabilitation, and long-term oxygen therapy. For preventative care, patients are now recommended to receive routine vaccination with the updated pneumonia vaccines, either one dose of PCV20 or one dose of PCV15 followed by PPSV23 ≥ 1 year later.
Clinical Impact: The 2023 COPD GOLD guidelines were updated to reflect the current evidence available. With the focus shifting to more LAMA/LABA and triple therapy inhaler use, cost and insurance coverage may prevent some patients from accessing or adhering to guideline directed therapy. Some manufacturers of these inhalers have drug coupons and patient assistance programs that some patients may be able to utilize to reduce financial burden of treatment. Pharmacists are in a unique position to assess if certain inhaler devices are working well for patients and if a change is needed to optimize patient adherence.
References:
- Venkatesan P. GOLD COPD report: 2023 update. Lancet Respir Med. 2023;11(1):18. doi:10.1016/S2213-2600(22)00494-5
- Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Arch Bronconeumol. 2023;59(4):232-248. doi:10.1016/j.arbres.2023.02.009
- Stonerock, Lauren. Pharmacy Times. As Easy as ABE: A Pharmacist’s Overview of Updates to the COPD GOLD Guidelines. Published April 4, 2023. Accessed April 10, 2023. https://www.pharmacytimes.com/view/as-easy-as-abe-a-pharmacist-s-overview-of-updates-to-the-copd-gold-guidelines
- Pyrls, Cosmas Health LLC 2023. Accessed April 10, 2023. www.pyrls.com