Key learning points
- Historically there was a gap in UK guidance after the NICE 2010 COPD guidelines, and many local UK guidelines were influenced by the annually-updated GOLD guidelines. In spite of the publication of the 2019 NICE COPD guidelines, GOLD continues to have a strong influence on local UK guideline formulation
- Diagnosis of COPD should be considered in the presence of characteristic symptoms, risk factors and airflow limitation
- The primary aims of COPD management are to reduce symptoms and future risk of exacerbations
- GOLD recommends dividing patients into four groups (A-D) based on their symptom severity and exacerbation frequency and basing initial pharmacotherapy on these groups
- Follow-up pharmacological treatment (escalation or de-escalation) is based on symptoms, exacerbations and peripheral blood eosinophil count; but is independent of the GOLD group at diagnosis
- Initiation and follow-up of non-pharmacological therapy forms an important part of a holistic and comprehensive COPD management approach
What are the GOLD guidelines?
The Global Initiative for Chronic Obstructive Disease (GOLD) guidelines were initially produced in 2001 to provide non-biased guidance on the diagnosis, management and prevention of COPD for a global audience of healthcare professionals. The guidelines are regularly updated with consensus recommendations by a Committee of recognised leaders in COPD research and clinical practice, as well as incorporating expert advice based on clinical experience. Unlike the National Institute for Health and Care Excellence (NICE) guidelines, they do not take into account cost-effectiveness of treatments. The most recent update was in 2021 and this version includes a new Chapter summarising the relevant key points regarding COPD in the context of COVID-19.1
History of GOLD guideline use in the UK
The latest version of the NICE COPD guidelines was published in 2018 and subsequently updated in July 2019.2 These updated guidelines, which replace the prior version published in 20113, have had to catch up on eight years of developments in COPD.4
During these eight years, the management of COPD changed dramatically such that the 2010 NICE guidelines were rendered out-of-date in terms of pharmacological treatment. As such, healthcare professionals in the UK looked to GOLD, which is updated every 18 to 24 months4, for the most current guidance. Whilst the most current GOLD (2021) and NICE (2019) guidelines are generally in broad agreement, differences still remain when it comes to pharmacotherapy.1,2,4
What are the key messages of GOLD 2021?
An important message from GOLD is that COPD is a common, preventable and treatable disease. It is characterised by persistent respiratory symptoms and airflow limitation due to airway and/or alveolar abnormalities.
COPD should be considered in any patient who is displaying characteristic symptoms (dyspnoea, chronic cough and/or sputum production); who has a history of recurrent lower respiratory tract infections; and/or who has a history of risk factors (e.g., exposure to cigarette smoke, exposure to indoor/outdoor air pollution, genetic factors and low birthweight). The diagnosis is confirmed by demonstration of persistent airflow limitation; post-bronchodilator FEV1/FVC ratio <0.7, with the use of spirometry that meets published standards. A good patient history, clinical examination and chest X-ray should be carried out to exclude differential diagnoses, for example lung cancer, and to establish the presence of significant comorbidities.
Assessment and management1
Following a diagnosis of COPD, GOLD (in line with NICE guidelines2) recommends that the following should be assessed to guide subsequent management.
Assessment for non-pharmacological management1
- Cigarette smoking
- Exposure to indoor/outdoor pollution
- Exercise and nutrition
- Oxygen status
- Presence of any psychological factors (e.g., depression)
- Presence of any comorbidities (e.g., osteoporosis, heart disease)
A central message of the GOLD guidance is that the aim of COPD management is to reduce both current symptoms and future risks of exacerbations:
- Reduce COPD symptoms: relieve symptoms, improve exercise tolerance, improve health status
- Reduce risk: prevent disease progression, prevent and treat exacerbations, reduce mortality
Pharmacological treatment regimens should be individualised and guided by several factors, including symptom severity, risk of exacerbations, side-effects and comorbidities.1It is recommended that symptom severity is reviewed after a suitable interval by the modified MRC dyspnoea score (mMRC)5 or by the COPD Assessment Test (CAT).6 Figure 1 shows the mMRC score. The CAT is an eight-item questionnaire looking at the impact that COPD symptoms have on patients’ wellbeing and daily life.
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 predictive of a patient being at high risk.7 GOLD reminds us that blood eosinophils may predict exacerbation rates, but insufficient evidence exists to recommend that they should be used to predict future exacerbation risk on an individual patient basis.1 However, GOLD now includes recommendations on the use of peripheral blood eosinophil counts as a biomarker to guide the use of ICS therapy to prevent exacerbations.1
The GOLD refined ABCD assessment tool and subsequent pharmacological treatment1
Following a spirometrically-confirmed diagnosis, GOLD recommends dividing patients into four groups (A-D), based on their symptom severity and exacerbation frequency (Figure 2).
Two separate algorithms are now recommended by GOLD for initiation and follow-up pharmacological treatment, shown in Figures 3 and 4, respectively. Initial treatment considers the individual patient assessment of symptoms and exacerbation risk following ABCD assessment. Follow-up management, whilst still based on symptoms and exacerbations, does not depend on the ABCD group at diagnosis. It is recommended that FEV1 is measured in the stable condition, but this alone should not be used to guide treatment.
Summary of GOLD pharmacotherapy recommendations1
Rescue short-acting bronchodilators should be used in all patients for immediate symptom relief.
GROUP A: Low symptoms, low risk
Use a bronchodilator. In practice this might be an inhaled short-acting beta-2 agonist (e.g., salbutamol and/or atrovent) for intermittent symptoms or a long-acting bronchodilator for persistent symptoms.
The bronchodilator should be continued if benefit is seen.
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 LABA/LAMA combination.
GROUP C: Low symptoms, high risk
Use a LAMA as first choice. For patients with severe breathlessness, initial therapy with two bronchodilators may be considered.
If exacerbations persist, consider a LAMA/LABA (first choice) or LABA/ICS (inhaled corticosteroid) combination.
GROUP D: High symptoms, high risk
Use a LAMA as first choice; consider LAMA/LABA in highly symptomatic patients; and consider LABA/ICS in patients with blood eosinophil count ≥300 or who have a history of, or are presenting with, asthma.
Consider triple LABA/LAMA/ICS therapy if exacerbations persist, or the addition of roflumilast (if FEV1 <50% and chronic bronchitis) or azithromycin (in former smokers).
Follow-up pharmacological management should be guided by the principles of review, assess and then adjust if needed:
- Review symptoms (dyspnoea) and exacerbation risk
- Assess inhaler technique and adherence, and the role of non-pharmacological approaches
- Adjust pharmacological treatment as needed
COVID-19 and COPD1
The COVID-19 pandemic has led to the need to modify pulmonary rehabilitation programmes under alternative conditions to enable physical distancing. The GOLD 2021 guidelines include a new comprehensive chapter on COVID-19 and COPD, including recommendations on investigations, protective strategies, maintenance pharmacological treatment, non-pharmacological treatment, review and follow-up. Importantly, GOLD recommend that patients should keep taking their oral and inhaled respiratory treatments as prescribed, as no evidence exists to suggest otherwise.
The GOLD guidelines provide a source of regularly updated guidance on pharmacological treatment for COPD, based on an individual patient’s symptomatology and the risk of future exacerbations.
Dr Kevin Gruffydd-Jones, GP in Warminster, Wiltshire; clinical adviser for the Royal College of General Practitioners, NICE, and policy committee member, Primary Care Respiratory Society