How the New GOLD Report Affects Your Patient’s COPD Journey

This post was written by Michael W. Hess, MPH, RRT, RPFT.

Much has been written about the new GOLD Strategy Report since it launched this past November. Considered one of the most significant revisions to the GOLD strategy in years, this latest iteration has many in the field rethinking how we look at the very definition of COPD. But the report also contains some major changes to initial therapy recommendations, not to mention refinements of ongoing therapeutic pathways. These changes have the potential to affect your clinical decision-making as your patients travel on their COPD journey, so it is important to not allow them to get overlooked.

A NEW GOLD BOX

Perhaps the most notable change is another revision to the “GOLD Box.” First seen over a decade ago, the Box was created to make more practical initial therapy recommendations based on exacerbation risk and symptom burden, rather than simply airflow obstruction. It has traditionally grouped people with COPD into four groups based on that risk and that burden, with suggested therapies based on the best evidence for their subcategory. However, newer evidence compiled in this year’s report suggests that for those people who have at least two exacerbations over the course of 12 months (or one that lands them in the hospital), symptom burden is far less clinically significant in terms of clinical relevance. Thus, the previous two high exacerbation risk groups (C and D) have been combined into a single group, E.

This admittedly does not seem like a major change at first glance. However, the treatment recommendations reflect ongoing refinements in best management of stable COPD. The new paradigm calls for all people in group E to be started on combination bronchodilator therapy. This is a step up from the old group C, which suggested only a long-acting muscarinic antagonist (LAMA) to start. It also represents a step away from jumping immediately into inhaled corticosteroids (ICS), as group D previously listed ICS used in conjunction with long-acting beta-agonist (LABA) bronchodilators) as a potential therapy option. To be clear, ICS is still an option in cases where blood eosinophil levels are found to be greater than 300, but it should only be prescribed as triple therapy.

The change also means that for the first time, virtually all newly-diagnosed people with COPD will start with essentially the same regimen. Combination bronchodilator therapy with both LABA and LAMA medications is now recommended as initial therapy for everyone with the exception of those in the low-symptom, low-exacerbation cohort, Group A. Evidence has been trending toward the use of both bronchodilator types for many years, and GOLD grants this therapy its highest level of confidence (Evidence A, or a large amount of high-quality evidence from randomized controlled trials without bias or significant limitations). This simplification should make it much easier for busy clinicians (especially in primary care) to better adhere to evidence-based practices while prescribing. This has been a long-standing issue in COPD, with one recent study suggesting 40% of people with COPD are not prescribed regimens in concordance with established clinical recommendations.¹

TREATABLE TRAITS AND NONPHARMACOLOGICAL THOUGHTS

The journey does not stop after the initial therapy prescription. For several years, GOLD has encouraged clinicians to follow a distinct management cycle, where the therapy plan is reviewed, adherence to the regimen (including inhaler technique) is evaluated, and treatment is escalated or de-escalated as appropriate. More recently, ongoing assessment has been focused on the “treatable traits” model, where therapy is adjusted to either improve dyspnea or reduce exacerbation frequency, depending on which is the primary concern. The latest GOLD report continues to refine these pathways, providing somewhat simplified algorithms to remind clinicians to evaluate other potential causes of dyspnea as well as consider non-inhaled medications such as roflumilast or azithromycin to lower the exacerbation risk. As another aid to busy clinicians, an excellent table of factors to consider when considering an inhaler device is provided to simplify these decisions.

Pulmonary rehab remains a cornerstone of treatment but also remains under-utilized and even difficult to access in certain areas. There have been many suggestions over the years on how to mitigate this, but the COVID-19 pandemic has accelerated the development of an intriguing option, virtual pulmonary rehab. The GOLD report takes a closer look at how feasible this modality may be beyond the pandemic. While stating that there is still a great deal still to understand about best practices, barriers, and other issues surrounding tele-rehab, it seems clear that as technology evolves, this could be a viable option down the road.

BIG CHANGES AHEAD

GOLD is careful to note that many of these recommendations are based on prior research and that additional studies looking at the new cohorts will be needed in order to validate these strategies. However, close followers of the GOLD report will also note that many of these treatment philosophies have been trending toward these recommendations for many years. The new report should go a long way toward supporting clinicians, standardizing care, and providing new research opportunities for a long time to come.