ASHP Midyear: 2025 GOLD Report Updates Highlight Cardiovascular Risks, New Therapies for COPD Patients

The 2025 GOLD Report on chronic obstructive pulmonary disease (COPD) management has been updated with several notable changes, Lourdes Cross, PharmD, BCACP, CDCES, associate professor at the Sullivan University College of Pharmacy & Health Sciences, said. A significant focus is placed on the increased cardiovascular risks faced by COPD patients, including higher rates of coronary artery disease and cardiovascular events during exacerbations. The report recommends close monitoring of COPD patients for both pulmonary and cardiac issues. It also includes new sections on pulmonary hypertension and the impacts of global climate change, which can exacerbate COPD symptoms. Treatment updates cover the incorporation of 2 recently approved therapies—the phosphodiesterase inhibitor enciphenterine and the biologic dipilimab.

Pharmacy Times: What are the current guidelines for COPD, and have there been any new and significant changes?

Lourdes Cross: The 2025 Gold Report was just updated in November, so there are a couple notable key changes there. They included some new sections. There's an expanded section on the risk of cardiovascular disease in our patients with COPD. So we know that that patient population has an increased risk for things like coronary artery disease, and we know that patients that have COPD exacerbations also have an increased risk of cardiovascular-related events. So there is a big push to make sure that we're following up with these patients closely for both COPD and cardiovascular issues. There's also a new section related to pulmonary hypertension, just really recommending tailored approach for our patients with COPD. There's a discussion on global climate change. here's data showing that with extreme temperatures, there's an increased risk of exacerbations and hospitalizations. So they just want to bring awareness to that issue. From a treatment standpoint, there weren't any major overhauling changes, but they did incorporate the 2 recently approved agents, enciphenterine and dipilimab. So entering phosphodiesterase 3 and 4 inhibitor and its place in therapy, per this updated report, is to use it in patients currently on [long-acting muscarinic antagonists (LAMAs) and long-acting beta-agonists (LABAs)]dual therapy, who continue to be symptomatic. For dipilimab, slightly different place in therapy. It's recommended in patients that have a history of hospitalizations and that have elevated eosinophil counts. So the studies that look at these patients, they had moderate-to-severe COPD; they had eosinophil counts of greater than 300 and again that exacerbation history.

Pharmacy Times: How can combination therapies (e.g., LAMA/LABA, ICS/LABA, ICS/LAMA) improve outcomes compared to monotherapy?

Cross: We have a lot of good data on using the combination therapies, a lot of data showing that they can help improve lung function, decrease exacerbations, improve quality of life by looking at various questionnaires compared to even like mono therapy. Now, when selecting combination therapies, we have to be very specific on which populations we're going to use them in. For example, like with our triple therapies, with like the [inhaled corticosteroids (ICS)] component, we need to be very mindful of like eosinophil counts. So for example, in a patient that has a high eosinophil count, then they may be the ones that benefit the most from that ICS therapy, showing decrease in exacerbations for example. Patients with low eosinophil count, they're not going to benefit as much, and we also show an increased risk of pneumonia. So being very specific in our patient selection for these combinations, looking at severity, hospitalizations, eosinophil, all of those are going to help us decide what's the best treatment for a patient.

Pharmacy Times: Under what circumstances might a patient be considered for stepping down therapy?

Cross: That is actually a really good question. I think oftentimes in clinical practice, we focus on like, escalation of therapy because COPD is a progressive disease, but there are some cases where we might want to de escalate therapy just because of risk. For example, someone is having adverse effects from a certain medication, and maybe in patients that have been stable for a long time, you might want to trial getting them off certain you know, therapies. So for example, our patients that are currently on like, triple therapy, or maybe they're started on ICS because they had an exacerbation, but maybe over time that ICS was never reassessed. So if those patients have been stable for a while, no exacerbations, we could potentially trial discontinuing the ICS component and seeing how they do the big thing is that we have a good care plan that we're monitoring them closely, looking for like destabilization to make sure that it is appropriate to keep that therapy discontinued.