The 2011 GOLD classification for COPD and the 2013 GOLD Updates
The GOLD guidelines that were published in 2011 included a new classification whereby symptoms and not just airflow limitation have now to be taken into account to guide the management of chronic obstructive pulmonary disease (COPD). COPD patients are now divided into four groups (A, B, C and D) according to their symptom/risk profile (see Table 1). The patient group determines the pharmacotherapy strategy recommended for stable COPD (see Algorithm for the Management of COPD).
Table 1: Combined severity assessment of COPD based on risk/symptom profile
|
SYMPTOMS |
|||
| PATIENT GROUP | Less symptoms mMRC=0-1; CAT<10 |
More symptoms mMRC≥2; CAT≥10 |
|
|
RISK |
High risk GOLD 3-4 (i.e. FEV1<50%) Exacerbations ≥2/year |
C |
D |
| Low risk GOLD 1-2 (i.e. FEV1≥50%) Exacerbations ≤1/year |
A |
B |
|
In 2013, further updates were published, which are summarised below.
New recommendations from GOLD 2013
- The clinical COPD Questionnaire, a self-administered short questionnaire developed to measure clinical control in COPD patients, has been shown to be valid and reliable.
- Long-term treatment containing inhaled corticosteroids should not be prescriberd outside their indications, due to the risk of pneumonia and the possibility of a slightly increased risk of fractures following long-term exposure.
- Phosphodiesterase-4 inhibitor (PDE4) monotherapy is no longer listed as a possible option.
- The combinations LAMA + PDE4 and LABA + PDE4 have been added as alternative choices for patients in group C (high risk, less symptoms).
- The combination ICS + LAMA + LABA is now listed among the recommended first choices in patients group D, as it was recognised that a few patients with newly recognised very severe COPD could benefit from starting with a triple therapy.
- ICS + LAMA combination is not listed as a treatment option anymore due to lack of evidence to justify its use.
- Indacaterol (once daily LABA with 24 hour duration of action) has been shown to have significantly greater bronchodilator effects than that of formoterol and salmeterol.
- Several drugs were added to the list of agents available to treat COPD. These include: LAMAs aclidinium and glycopyrronium (Seebri Breezhaler), and LABA/ICS combination formoterol/mometasone in one inhaler (currently not available in Ireland).
- Additionally, the LABA/LAMA combination indacaterol/glycopyrronium is available in one inhaler (Ultibro Breezhaler) since December 2013.
References:
1- Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2013. Available from: http://www.goldcopd.org/.
2- Gruffydd-Jones K. GOLD guidelines 2011: what are the implications for primary care? Prim Care Respir J 2012; 21(4): 437-441.