Updated COPD Guidelines: Treatment & Management Options

The Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report, which highlights changes in diagnosis, de-escalation therapy, nonpharmacologic therapies, and multicomorbidity management, has just been published online (Am J Respir Crit Care Med; doi:10.1164/rccm.201701-0218PP).

Twenty-two COPD experts reviewed published research through October 2016 to compile the best recommendations in the report.

One of the key changes in the revision is the separation of symptom evaluation from spirometric assessment. Although spirometry remains necessary to make the diagnosis, assessment goals should focus on symptoms, risk for exacerbations, and determining the effect of the disease on the patient's overall health. That assessment can then be used to place individual patients in the A, B, C, and D groups that guide therapy.
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“The major change was peeling off spirometry and making spirometry a diagnostic and obstruction severity marker, but removing it from pharmacologic considerations in principle, with one exception,” said report coauthor Fernando Martinez, MD, chief of the Division of Pulmonary and Critical Care Medicine at Weill Cornell Medical Center/NewYork-Presbyterian Hospital in New York City (eg, Medscape. February 2, 2017).

“Spirometry remains a key diagnostic feature and an important modality in defining severity of airflow obstruction,” he said. “Therapeutically, it has limited relevance for pharmacotherapeutic options except for roflumilast. It does have relevance for nonpharmacologic therapies, including lung volume reduction and lung transplantation.”

As before, the guidelines recommend evaluation for COPD in individuals with a history of risk factors or with dyspnea, chronic cough, or sputum production, using a postbronchodilator FEV₁/FVC < 0.70 cutoff for diagnosis. In addition to family history, risk factors from childhood include low birthweight and childhood respiratory infections. Other risk factors include exposure to tobacco smoke, home cooking or heating fuels smoke, and occupational dusts, vapors, fumes, gases, and other chemicals.

Another addition to the new GOLD report is an in-depth discussion of escalation and de-escalation treatment strategies, whereas past reports primarily focused only on initial therapy recommendations.

The updated GOLD report further adds a thorough review of nonpharmacologic treatment options, in addition to receiving influenza and pneumococcal vaccinations to decrease the risk for lower respiratory tract infections. The most important aspect of any treatment plan remains smoking cessation, and pulmonary rehabilitation remains highly beneficial.

Referring to the expanded discussion on managing comorbidities in COPD patients, Dr Martinez said, “There remains strong emphasis on the understanding of diagnosing and managing comorbid conditions in the COPD patient…. There's also a later emphasis and description on the role of palliative care and comprehensive disease management.”

According to Dr Martinez, the GOLD statement is annually updated as needed, but undergoes a major revision every few years as more evidence emerges and requires consideration in clinical practice changes.

“This is the next due major revision, and we took the opportunity based on the feedback that we had received after the last major revision to make modifications that simplified the recommendations and added additional evidence base to make the therapeutic schema more practical and easy to apply in a broad range of clinical settings,” he said.—Amanda Del Signore