Recommended Changes for Next GOLD Guidelines Update

Following the release of the 2018 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, a group of pulmonary clinicians and researchers from the Mayo Clinic have critiqued and recommended several changes to the next major update to GOLD in a recent paper.

Although the 2018 guidelines are a minor update to the 2017 report, the clinicians from the Mayo Clinic noted that the burden of COPD is experienced worldwide and in the United States. Currently, COPD is the third-leading cause of death.

“The majority of people with COPD have mild disease that requires very little treatment other than smoking cessation and possibly a short-acting bronchodilator,” Paul Scanlon, MD, Mayo Clinic pulmonologist and the article’s senior author, said in a press statement. “For the minority of people with more advanced disease, current therapy is very effective, improves symptoms and quality of life, increases exercise tolerance, and reduces frequency of exacerbations.”

The current guidelines include 3 features to COPD diagnosis. The features include:

• a postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of less than 0.70, to confirm persistent airflow limitation;
• symptoms such as dyspnea, chronic cough, sputum production, or wheezing; and,
• “significant exposures to noxious stimuli,” which includes a history of smoking cigarettes or other environmental exposures, although GOLD does not quantify smoking history.

According to the 2018 update, the guidelines recommend repeat spirometry for patients with an initial FEV1/ FVC ratio in the 0.6 to 0.8 range to account for variability and to increase specificity. However, the researchers from the Mayo Clinic feel that a fixed ratio contributes to overdiagnosis of airflow obstruction in older patients and, to a lesser degree, and underdiagnosis in younger patients. Further, they said they wished the GOLD guideline experts had decided to use a lower limit, as recommended by respiratory societies. The researchers also noted that the guidelines rely on “persistent” symptoms and exacerbation frequency to determine therapy specifics. They explained that because some patients have the ability to adapt their lifestyle and mask symptoms, asymptomatic or intermittently symptomatic patients may be underdiagnosed.

Other than changes for diagnosis, the researchers also made recommendations for patient comorbidities, smoking and e-cigarette use, and asthma-COPD overlap syndrome.

According to the researchers, patients with COPD are more likely to die of COPD-related diseases rather than the disease itself. The most common COPD-related diseases include lung cancer, cardiovascular disease, stroke, osteoporosis, anxiety and depression, sleep apnea, gastroesophageal reflux, diabetes, and bronchiectasis. The researchers explained that these diseases need to be treated according to their usual standards of care and treatment should not be withheld due to the existence of COPD. The researchers also noted that many of the COPD-related disease are linked to tobacco use. They recommended that the next update should include a discussion of risks, benefits, and recommendations around e-cigarette use, citing its attractiveness to youth and other concerns. 

Finally, the researchers said the new update should include a more in-depth discussion of asthma-COPD overlap syndrome. Currently, the 2017 GOLD update only briefly mentions the syndrome. The researchers recommend comprehensive pulmonary rehabilitation programs, including the use of motivational interviewing–based health coaching, to try to improve patients’ quality of life and reduce psychological distress.

The report notes the continued challenge, which includes the economic challenge, of treating recurrent or persistent exacerbations in patients with asthma-COPD overlap syndrome.

“As we move toward value-based, high-quality care, US hospitals with unacceptably high 30-day readmissions may face penalties such as reduced reimbursement,” the authors wrote. “The degree to which such penalties may disproportionately affect hospitals that care for the socioeconomically disadvantaged is unknown.”

—Julie Gould

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