Margaret Mattson, PharmD, St. Cloud VA Health Care
Background
Chronic obstructive pulmonary disease (COPD) is a lung condition characterized by persistent airflow obstruction due to airway and/or alveolar abnormalities. Patients with COPD often present with chronic respiratory symptoms such as sputum production, dyspnea, and exacerbations. Risk factors for the development of COPD include tobacco smoking, inhalation of toxic particles (often from working or living in areas with significant air pollution), and abnormal lung development. Reducing exposure to risk factors and diagnosing COPD early are important steps in preventing disease progression. Effective treatments are available and should be used based on guideline recommendations, with inhaled bronchodilators and corticosteroids serving as the mainstay of therapy. However, many barriers to effective COPD treatment exist, including limited access to care and appropriate diagnostic testing, the high cost of inhaler therapies, and challenges with adherence to complex inhaler regimens. The primary goals of COPD treatment are to relieve symptoms and prevent disease progression.
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are the primary treatment guidelines for COPD. The GOLD was established in 1998 by the National Heart, Lung, and Blood Institute (NHLBI), National Institutes of Health (NIH), and the World Health Organization (WHO) to increase awareness of COPD and improve COPD prevention and management worldwide. The guidelines are updated annually to reflect new research, treatment guidance, and management recommendations.
Discussion
The 2026 GOLD Report was published in November 2025. While the primary treatment goals and medication classes remain largely unchanged, the latest report addresses several clinically important updates.
First, the 2026 GOLD Report includes updated criteria for defining GOLD A, B, and E categories, which directly impact pharmacotherapy selection. Patients with one or more moderate or severe COPD exacerbations in the past year are now classified as group E and should be prescribed a long-acting muscarinic antagonist (LAMA) and long-acting beta agonist (LABA), with or without an inhaled corticosteroid (ICS), regardless of modified Medical Research Council (mMRC) or COPD Assessment Test (CAT) score (Table 1). Previous guidance classified patients as group E if they had two or more moderate exacerbations or one or more severe exacerbations requiring hospitalization, while those with fewer or less severe exacerbations were categorized as groups A or B based on mMRC or CAT score. This change was driven by updated evidence from observational studies demonstrating that patients with one or more exacerbations prior to initiating pharmacotherapy are at increased risk of future exacerbations. By lowering the threshold for Group E classification, the earlier initiation of dual bronchodilator therapy proactively supports the achievement of low disease activity and the prevention of future exacerbations.
One or more moderate or severe exacerbations in the previous year | Zero moderate or severe exacerbations in the previous year (mMRC 0-1, CAT < 10) | Zero moderate or severe exacerbations in the previous year (mMRC ≥ 2, CAT ≥ 10) |
|---|---|---|
Group E: LABA + LAMA (Consider LABA+LAMA+ICS is blood eosinophils are ≥ 300) | Group A: bronchodilator | Group B: LABA + LAMA
|
Second, the 2026 GOLD Report has added an additional biologic agent (mepolizumab) to the existing treatment options of LAMA, LABA, and ICS inhalers, antibiotics, and dupilumab (Dupixent). Mepolizumab is dosed less frequently than dupilumab (Dupixent) and can be used in patients with or without chronic bronchitis. Previously, dupilumab was the only approved biologic recommended in the guidelines and was recommended specifically for patients with chronic bronchitis.
Third, updated vaccination recommendations for patients with COPD are also included in the 2026 GOLD Report. These recommendations are based on WHO and Centers for Disease Control and Prevention (CDC) guidance. The notable update in the 2026 GOLD Report is the younger age recommendation for the RSV vaccine, which is now recommended for patients aged 50 years or older (previously recommended for 60 years or older). Other vaccination recommendations for patients with COPD, including influenza, COVID-19, pneumococcal, Tdap, and zoster vaccines, remain unchanged.
Clinical Impact
Consistent with previous treatment guidelines, initial pharmacotherapy management is dependent on categorization into GOLD groups A, B, or E. Patients categorized as GOLD A should be treated with a bronchodilator, patients categorized as GOLD B should be treated with a LABA plus LAMA, and patients categorized as GOLD E should be treated with LABA plus LAMA with or without ICS. The recommendations for medication classes used remain largely unchanged in the 2026 GOLD Report. However, the clinical impact of this update lies in the lower threshold for more aggressive treatment initiation, and an increased emphasis on vaccination to protect patients from respiratory viral infections. Providers should be aware of the updated guideline recommendations to ensure they are adequately treating patients in alignment with the new, more proactive treatment guidelines.
Published on March 4th, 2026.
References
- Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD: 2026 Report. Published November 17, 2025. Accessed February 1, 2026. https://www.goldcopd.org
- Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management and Prevention of COPD: 2025 Report. Published November 14, 2024. Accessed February 1, 2026. https://www.goldcopd.org