Originally published: September 2017

Key learning points

  • New evidence into chronic obstructive pulmonary disease (COPD) means that GOLD guidelines may be more relevant to practice than the NICE COPD guidelines
  • Diagnosis of COPD should be considered in the presence of characteristic symptoms, risk factors and airflow limitation
  • Aims of COPD management are to reduce symptoms and future risk
  • GOLD recommends dividing patients into four groups (A-D), based on their symptom severity and exacerbation frequency and basing pharmacotherapy on these

What are they?

The Global Initiative for Chronic Obstructive Disease (GOLD) guidelines were initially produced in 2001 and were intended to provide guidance on the diagnosis and management of COPD for a global audience of health professionals. They are evidence based to a degree, but largely rely on consensus among a committee of mainly secondary care international chest physicians. Unlike the National Institute for Health and Care Excellence (NICE) guidelines, they do not take into account cost-effectiveness of treatments. They are updated regularly with the latest update being 2017.

Why should we bother about GOLD Guidelines in the UK?

The latest version of the NICE COPD guidelines was published in 2010.1 The pharmacological treatment algorithm was based on the degree of airflow limitation as measured by the forced expiratory volume in 1 second (FEV1), and on the evidence and pharmacological options available at that time.

In recent years there has been increasing realisation that the degree of airflow limitation is less related to disease severity compared to more patient-centred outcomes such as the degree of symptoms and exacerbation frequency. In addition there has been new evidence surrounding the role of inhaled bronchodilators and inhaled steroid therapies, and new combinations. This has rendered the NICE guidelines regarding treatment out of date and so health professionals in the UK have looked to GOLD for guidance.

What are the key messages of GOLD 2017?2

Definition

An important message from GOLD is that COPD is common, preventable and treatable.

Diagnosis2

A diagnosis of COPD should be considered in the presence of characteristic symptoms (dyspnoea, chronic cough and/or sputum production) and in the presence of risk factors (eg cigarette smoke, indoor/outdoor pollution). The diagnosis is confirmed by demonstration of persistent airflow limitation; post bronchodilator FEV1/FVC ratio <0.7, with spirometry that meets published standards. A good patient history, clinical examination and chest X-ray should be carried out to exclude other conditions causing the symptoms, for example lung cancer, and to look for other comorbidities.

Assessment and management

Once a diagnosis of COPD has been made then GOLD (in line with NICE guidelines) recommends that the following should be assessed to guide subsequent management.

Non-pharmacological management2

  • Cigarette smoking
  • Indoor/outdoor pollution
  • Exercise and nutrition
  • Oxygen status
  • Psychological factors eg depression
  • Comorbidities eg osteoporosis, heart disease

Pharmacological  management

A central message of the GOLD guidance is that the aims of COPD management are to:

  • Reduce symptoms: relieve symptoms, improve exercise tolerance, improve health status
  • Reduce risk: prevent disease progression, prevent and treat exacerbations, reduce mortality

It is recommended that symptom severity is measured by the modified MRC dyspnoea score (mMRC)3 or by the COPD assessment test (CAT).4 Figure 1 shows the mMRC score. The CAT is an eight item questionnaire looking at the impact of COPD symptoms on the patient.

Figure 1: Modified MRC (mMRC) questionnaire3

A major determinant of future risk of exacerbations is a history of previous exacerbations (requiring oral steroids/antibiotics/hospital admission). A history of two or more exacerbations in the previous 12 months is a predictor of high risk.5 GOLD also reminds us that blood eosinophils may predict exacerbation rates.2

GOLD recommends dividing patients into four groups (A-D), based on their symptom severity and exacerbation frequency. Figures 2 and 3 show the categorisation and recommended pharmacological treatment. It is also recommended that FEV1 is measured in the stable condition although this does not guide treatment:

Figure 2: Refined ABCD assessment tool6

Reprinted with permission of the American Thoracic Society. Copyright© 2017 American Thoracic Society.

Vogelmeier CF, Criner GJ, et al. American Journal of Respiratory Critical Care Medicine 2017;195(5):557-582. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.
Figure 3: Pharmacological treatment algorithms6

Reprinted with permission of the American Thoracic Society. Copyright© 2017 American Thoracic Society.

Vogelmeier CF, Criner GJ, et al. American Journal of Respiratory Critical Care Medicine 2017;195(5):557-582. The American Journal of Respiratory and Critical Care Medicine is an official journal of the American Thoracic Society.

Summary of GOLD pharmacotherapy recommendations2

GROUP A: Low symptoms, low risk

Use a bronchodilator. In practice this might be an inhaled short acting beta-2 agonist (eg salbutamol and/or atrovent) for intermittent symptoms or a long-acting bronchodilator for persistent symptoms.

GROUP B: High symptoms, low risk

Use long-acting beta-2 agonist (LABA) or long-acting antimuscarinic agent (LAMA). If symptoms persist GOLD advise to use a LAMA/LABA combination.

GROUP C: Low symptoms, high risk

Use a LAMA as first choice. If exacerbations persist consider a LAMA/LABA (first choice) or LABA/ICS (inhaled corticosteroid) combination.

GROUP D: High symptoms, high risk

Use LABA/LAMA (or LABA /ICS if there is co-existent asthma). Consider triple LABA/LAMA/ICS therapy if continued exacerbations.

Addition of roflumilast (an oral phosphodiesterase inhibitor, recently approved by NICE), or long-term macrolide therapy should be considered if there is no response. These two decisions should be made in secondary care.

Before escalation of any therapy it is important to check correct inhaler technique and compliance.

Conclusion

The 2010 NICE guidelines have become outdated with regards  to pharmacological management of COPD. The GOLD guidelines provide up-to- date guidance on pharmacological treatment based on an individual patient’s symptomatology and the risk of future exacerbations.

Dr Kevin Gruffydd-Jones is a GP trainer and principal in Box, Wiltshire. He was education lead of the Primary Care Respiratory Society and is currently joint clinical policy lead of the group.

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