The 2017 Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report has been released which includes updated recommendations for the diagnosis and management of chronic obstructive pulmonary disease (COPD). The GOLD Report provides clinicians with a non-biased review of the current evidence available for the management of COPD patients. Some of the new recommendations include a revision to the definition of COPD, recommendations for noninvasive ventilation, oxygen therapy, and lung volume reduction, as well as a shift toward personalized treatment approaches with strategies for escalating and de-escalating drug therapy.
Per the new guidelines, for patients with stable COPD, the main treatment goal would be to reduce symptoms and future exacerbation risk. With this in mind, the GOLD Report includes the following key recommendations for personalizing treatment in stable COPD (evidence levels run from the highest level A [large, well-controlled trials] to the lowest level D [insufficient, based on clinical experience]):
- Long-acting beta2 agonists (LABAs) and long-acting muscarinic agonists (LAMAs) preferred over short-acting drugs except for occasional dyspnea (A)
- Single or dual long-acting bronchodilators may be used as initial therapy; escalate to two bronchodilators if one is not achieving desired effect (A)
- Inhaled bronchodilators preferred over oral bronchodilators (A)
- Theophylline not recommended; only to be used if other long-term treatments are not available or unaffordable (B)
- Long-term therapy with inhaled corticosteroids (ICS) or oral corticosteroids: not recommended (A)
- For patients with a history of exacerbations despite treatment with long-acting bronchodilators, long-term ICS may be considered with LABAs (A)
- If exacerbations continue with LABA/ICS or LABA/LAMA/ICS, chronic bronchitis, severe to very severe airflow obstruction: consider adding PDE4 inhibitor (B)
- Consider macrolides in former smokers with exacerbations despite therapy (B)
- Statin therapy to prevent exacerbations: not recommended (A)
- Antioxidant mucolytics: only recommended for select patients (A)
- Severe hereditary alpha-1 antitrypsin deficiency, established emphysema: consider possible alpha-1 antitrypsin augmentation therapy (B)
- Antitussives: no recommendation available (C)
- Pulmonary hypertension (PH) secondary to COPD: drugs FDA-approved for primary PH not recommended (B)
- Dyspnea in severe COPD: low-dose long-acting oral and parenteral opioids may be considered (B)
Treatment strategy is based on the group (calculated by disease severity; Groups B, C, D have high symptom burden and exacerbation risk) in which the COPD patient belongs.
For Group A patients, a bronchodilator (short- or long-acting) can be offered; if necessary, an alternative class of bronchodilator can be used if benefit is not achieved with the first.
For Group B patients, therapy should begin with a long-acting bronchodilator (no evidence to recommend one over another), and should be escalated to two bronchodilators if breathlessness continues with monotherapy. If breathlessness is severe, starting the patient on dual long-acting bronchodilators can be considered, however if the second therapy does not improve symptoms, the guidelines suggest stepping down to one bronchodilator. Group B patients may also have comorbidities that contribute to their symptoms and these should be assessed when deciding on how to treat the patient.
For Group C patients, it is recommended that treatment be started with a single long-acting bronchodilator, preferably a LAMA. A second long-acting bronchodilator or the combination of LABA/ICS may be used for persistent exacerbations; the guidelines recommend LABA/LAMA as the addition of ICS has been shown to increase pneumonia risk in some patients.
For Group D patients, a LABA/LAMA combination is preferred as initial therapy over LABA/ICS as these patients may be at higher risk of developing pneumonia with ICS use. For patients with high blood eosinophil counts or those with asthma-COPD overlap, LABA/ICS could be considered first-line therapy. Two pathways are recommended for patients who have further exacerbation with LABA/LAMA: 1) adding ICS to the regimen or 2) switching to LABA/ICS, although there is no evidence to say this will improve exacerbations (if symptoms do not improve, LAMA may be added). For patients who still have exacerbations with LABA/LAMA/ICS, the following three options can be considered: 1) adding roflumilast (for patients with FEV1<50% predicted and chronic bronchitis); 2) adding a macrolide (azithromycin preferred, however, antibiotic resistance should be factored in decision-making); 3) discontinuing ICS.
The guidelines also provide the following recommendations for pharmacologic management of exacerbations:
- Initial therapy for acute exacerbations: short-acting inhaled beta2 agonists w/wo short-acting anticholinergics (C)
- Systemic corticosteroids: may improve FEV1, shorten recovery (duration: no more than 5–7 days) (A)
- Antibiotics, when indicated: may shorten recovery, reduce relapse, treatment failure (duration: no more than 5–7 days) (B)
- Methylxanthines: not recommended (increased adverse effects) (B)
Non-pharmacologic treatment strategies (ie, smoking cessation, physical activity, pulmonary rehabilitation programs, self-management education, nutritional support, oxygen therapy, interventional bronchoscopic and surgical treatments) are also discussed in great detail.
To review the entire report visit GOLDCOPD.org.