GOLD Guidelines Provide Recommendations on Managing COPD

Chronic pulmonary disease (COPD) is a common, preventable disease characterized by airflow limitation and persistent respiratory symptoms.

Respiratory symptoms include cough, dyspnea, and sputum production, and patients may experience brief episodes of acute worsening respiratory symptoms known as exacerbations. COPD is commonly associated with significant concomitant chronic diseases that increase its morbidity and mortality.¹

COPD affects approximately 1 in 10 individuals globally and its prevalence increases daily. The highest related mortality is seen in China, India, Latin America, Southeast Asia, and sub-Saharan Africa. Air pollution, indoor and outdoor fumes, and smoking are major risk factors for COPD, and though many risk factors may precipitate it, the disease is still underdiagnosed. Further emphasis on risk factor identification and screening is needed to improve diagnosis, which would hopefully improve the disease’s progression.²

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations on the diagnosis, management, and prevention of COPD. The new recommendations of the 2022 update¹ pertain to pharmacological management and pulmonary rehabilitation of COPD.

Pulmonary rehabilitation has been outlined in the GOLD guidelines as a comprehensive intervention based on patient assessment, and it is individualized to each patient. It includes education, exercise training, and self-management aimed at eliciting behavioral changes to improve the management of chronic respiratory diseases. Pulmonary rehabilitation improves dyspnea, exercise tolerance, and health status and reduces anxiety and depression for patients with COPD. Pulmonary rehabilitation has also been shown to reduce hospitalization for patients who have had exacerbations 4 weeks or less from prior hospitalization. In terms of self-management, communication with health care professionals is recommended to help decrease emergency department visits.

One important new finding in the updated guidelines was the increased risk of respiratory disease among existing and former e-cigarette users, and this was he case even when outcomes were adjusted for factors, such as chronic health conditions, cigarette and other combustible tobacco product use, and demographics. This was derived from a large prospective cohort study³ of more than 20,000 patients lasting for 5 years. The guidelines recommend an annual low-dose computer tomography scan to assess for lung cancer in patients with COPD related to smoking. Another recent nonpharmacological management strategy involves shielding measures, such as frequent handwashing, mask-wearing, and social contact minimization during winter months to mitigate exacerbations. These measures have been commonly used by many individuals with or without COPD during the COVID-19 pandemic, and this may have prompted the idea that these measures can be particularly useful in patients with COPD.

Another way the COVID-19 pandemic affected the guidelines was an update to recommend COVID-19 vaccination for patients with COPD in line with national recommendations.⁴ The guidelines also newly recommend zoster vaccination to protect against shingles for adults with COPD 50 years or older. Other recommended vaccinations previously mentioned in the 2021 version⁵ included those for influenza, pertussis (Tdap and dTaP), and pneumonia (PCV13 and PPSV23).

The guidelines also discuss the use of theophylline in the management of COPD. Theophylline is a methylxanthine that may function as a nonselective phosphodiesterase inhibitor, but it has been reported to have a range of nonbronchodilators with the significance of effects disputed. Although there is evidence that theophylline has a modest bronchodilator effect compared with the placebo in stable COPD, the guidelines mention a large placebo-controlled trial⁶ that showed no effect of oral theophylline alone or in combination with prednisolone 5 mg daily on the exacerbations of severe COPD.

Pharmacological treatments for COPD also include inhaled corticosteroids (ICS), long-acting β2-agonists (LABA), and long-acting muscarinic antagonists (LAMA). They can be used individually or in various combinations, depending on the course of COPD. The use of all 3 agents simultaneously is known as triple therapy and is recommended in patients who continue to have exacerbations or symptoms while receiving a dual therapy regimen of LABA/LAMA or ICS/LABA. In a large randomized trial⁷ that studied the efficacy and safety of triple therapy at 2 dose levels of patients on ICS therapy with moderate to very severe COPD and at least 1 exacerbation in the past year, the use of triple therapy (ICS/LABA/LAMA) containing the higher dose of ICS led to lower mortality compared with dual therapy (LABA/LAMA).

When considering the effect of overall pharmacotherapy for COPD in slowing the rate of forced expiratory volume (FEV1) decline, the guidelines mention a systematic review⁸ of 9 studies that showed a reduction in the rate of FEV1 decline of 5.0 mL/year in the active treatment arms compared with the placebo arms. The review specifically found differences of 7.3 mL/year with respect to inhaled cortcosteroids and 4.9 mL/year with respect to long-acting bronchodilators, though further research is needed to know which specific patients would benefit.

Conclusion

The GOLD guidelines are a pivotal resource available to clinicians to improve the diagnosis, management, and prevention of COPD. The COVID-19 pandemic has clearly contributed to the changes in the 2022 update of the guidelines, and the future course of this pandemic, as well as the emergence of other epidemics in the future, may further alter clinicians’ approaches to managing COPD. The fact that COPD is now 1 of the top 3 causes of death worldwide further highlights the need for clinicians to stay up to date with evidence-based recommendations to diagnose, manage, and prevent COPD.

REFERENCES

1. 2022 GOLD reports. Global Initiative for Chronic Obstruc-tive Lung Disease. Accessed October 24, 2022. https://goldcopd.org/2022-gold-reports-2/

2. Halpin DMG, Vogelmeier CF, Agusti A. Lung health for all: chronic obstructive lung disease and World Lung Day 2022. Am J Respir Crit Care Med. 2022;206(6):669-671. doi:10.1164/rccm.202207-1407ED

3. Xie W, Kathuria H, Galiatsatos P, et al. Association of electronic cigarette use with incident respiratory conditions among US adults from 2013 to 2018. JAMA Netw Open. 2020;3(11):e2020816. doi:10.1001/jamanetworkopen.2020.20816

4. Thompson MG, Stenehjem E, Grannis S, et al. Effectiveness of COVID-19 vaccines in ambulatory and inpatient care settings. N Engl J Med. 2021;385(15):1355-1371. doi:10.1056/NEJMoa2110362

5. Halpin D. GOLD COPD strategy: what’s new for 2021? Guidelines in Practice. February 24, 2021. Accessed October 24, 2022. https://www.guidelinesinpractice.co.uk/respiratory/gold-copd-strategy-whats-new-for-2021/455824.article

6. Jenkins CR, Wen FQ, Martin A, et al. The effect of low-dose cortico-steroids and theophylline on the risk of acute exacerbations of COPD: the TASCS randomised controlled trial. Eur Respir J. 2021;57(6):2003338. doi:10.1183/13993003.03338-2020

7. Rabe KF, Martinez FJ, Ferguson GT, et al. Triple inhaled therapy at two glucocorticoid doses in moderate-to-very-severe COPD. N Engl J Med. 2020;383(1):35-48. doi:10.1056/NEJMoa1916046

8. Celli BR, Anderson JA, Cowans NJ, et al. Pharmacotherapy and lung function decline in patients with chronic obstructive pulmonary disease. A systematic review. Am J Respir Crit Care Med. 2021;203(6):689-698. doi:10.1164/rccm.202005-1854OC