Physician's Weekly Article - Managing COPD: An Update on GOLD Standards

       Updated guidelines by the Global Initiative for Chronic Obstructive Lung Disease provide new essential recommendations on the diagnosis, management, and prevention of chronic obstructive pulmonary disease.

      In 2007, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released new recommendations for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (COPD). The review has been the first full evaluation of the document since the GOLD report was originally published in 2001. The new standards provide healthcare professionals with state-of-the-art information on the most appropriate management and prevention strategies of COPD based on current validated concepts of COPD pathogenesis. Emerging literature have allowed the GOLD initiative to provide revisions in the evaluation and monitoring of disease activity to better reduce preventable or treatable risk factors, manage stable COPD, and manage exacerbations.

      Assessing COPD Severity

      Bronchodilator medications are central to the symptomatic management of COPD. Post-bronchodilator forced expiratory volume in 1 second, or FEV₁, is recommended for the diagnosis and assessment of disease severity; suggested therapy is dependent on the state of severity (Figure 1). The new spirometric classification of severity of COPD now includes only four stages: mild (I), moderate (II), severe (III), and very severe (IV). The fifth group that appeared in the 2001 report—“stage 0, at risk”—has been excluded in the new recommendations. “When the report was first published, there was little data available to support the stratification of patients with COPD,” says Antonio Anzueto, MD. “However, current studies have shown that patients at risk for COPD do not necessarily progress to stage I. As a result, they are now classified separately from those who actually have the disease.”

      Although those at risk are no longer classified with a stage of COPD, Dr. Anzueto says that it is still essential for physicians to recognize COPD risk factors, such as cigarette smoking. “Smoking is the most common risk factor for COPD in addition to long-term exposure to occupational dusts and chemicals and biomass,” he says. “Biomass exposure is a strong risk factor outside of the United States, such as in Latin America and China.” In addition, clinical investigations have shown that about 15% to 25% of adults aged 40 or older may have airflow limitation categorized as stage I or higher—and incidence of COPD in this population is significantly higher in smokers and ex-smokers than in non-smokers.

      Exploring the Dangers of Exacerbations

      “One of the major emphases in the updated GOLD recommendations is the danger of exacerbations,” says Dr. Anzueto. “COPD exacerbations are associated with significant injury to patients, and are the primary factors contributing to morbidity and mortality associated with the disease. A comprehensive assessment of management is now provided, and it’s recognized that chronic therapy significantly improves exacerbations [Table 1]. Patients who receive chronic therapy have fewer exacerbations, which positively impacts the evolution of the disease.”

      Regular treatment with long-acting bronchodilators has been effective chronic therapy that can reduce the rate of COPD exacerbations. According to Dr. Anzueto, it is no longer acceptable for physicians to use short-acting bronchodilators as monotherapy. “In the past,” he says, “patients have been administered albuteral or ipratropium every 4-to-6 hours even though we lacked the research to support that treatment. However, the new guidelines stress that the objective of standard therapy is not to temporarily assist a patient’s breathing, but to reverse the course of the disease. The only way therapy can result in long-term benefits for patients is by slowing the progression of the disease. Research has shown that this can be achieved through the use of long-acting bronchodilators.”

      Form a Multidisciplinary Team

      A multidisciplinary healthcare team is important to improve COPD outcomes in patients with comorbidities. “Physicians must recognize that patients who have COPD often suffer from other medical conditions as well, such as coronary artery disease, diabetes, or hypertension,” says Dr. Anzueto. “Primary care physicians and specialists need to be aware of all existing medical conditions and work together to ensure that they’re addressed.” Although the guidelines recommend that establishing this team is critical, they note that considerable work is required to determine the most effective methods to achieve a successful collaboration.

      “With continuous advancements in research into COPD, the disease is now being labeled as preventable and treatable,” says Dr. Anzueto. “Regardless, further refinements are required to identify areas of weakness that will better manage this major national health problem.”

      Dr. Anzueto has indicated to Physician’s Weekly that he has been a consultant, on advisory boards for, and a speaker for Altana, Chiron, Pfizer, Bayer-Schering Pharma, Aventis, Boehringer-Ingelheim, Ortho-MacNeil, and Schering-Plough.