Additions to GOLD for 2021 provide guidance on pandemic and triple therapy

Key changes to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for 2021 include a whole new chapter on managing COVID-19 and COPD during the pandemic and a checklist for carrying out remote consultations.

The additional section on COVID-19 recommends that any COPD patient presenting with new or worsening respiratory symptoms, fever and or any other symptom that could be related to Covid-19, even if mild, should be tested.

But it reiterates that there is no evidence that COPD medications should be changed as a result of the pandemic.

When there are high levels of COVID-19 in the community, spirometry should be restricted to patients requiring urgent or essential tests for the diagnosis of COPD or assessing lung function status for interventional procedures or surgery, the GOLD update recommends.

It includes guidance for remote consultations for COPD patients during the pandemic and warns that patients must try to keep active and socially connected even if they are shielding.

Professor David Halpin, Consultant Physician and Honorary Professor of Respiratory Medicine at University of Exeter Medical School and lead on the new COVID-19 chapter in the GOLD guidelines said there were practical challenges in managing COPD patients with COVID-19.

“One thing we talk a little bit about in the chapter is the concept of long-COVID. If patients have ongoing breathlessness or exacerbations it will raise questions about whether it’s COPD or whether it’s long-COVID and that will need investigating so this will be a significant workload for respiratory teams for many years to come.”

He added that the checklist for remote consultations would likely be useful in the longer term as telemedicine becomes embedded in routine practice.

The GOLD updated guidance also includes more detail on the evidence of triple therapy on mortality after two large randomised trials – ETHOS and IMPACT – published new data.

Together the results suggest a beneficial effect of fixed-dose triple inhaled therapy versus fixed-dose LABA/LAMA combinations on mortality in symptomatic COPD patients with a history of frequent and/or severe exacerbations who were previously receiving maintenance therapy with triple therapy, LABA/ICS or single or dual long-acting bronchodilators.

Further analyses or studies may help to determine whether other specific patient subgroups show a greater survival benefit, the guidelines concluded.

Professor Halpin said the additional data on mortality didn’t change the positioning of triple therapy in the recommendations but was reassuring.

“It does make it clearer what the benefits are, especially in these groups of patients. It’s really exciting that we now have treatments in COPD that have a proven effect on mortality.”

Other updates include the recommendation to offer pertussis vaccination in adults with COPD who were not vaccinated in adolescence.

And the GOLD report has also added reference to the World Health Organization (WHO) minimum set of interventions for the diagnosis of COPD and the management of exacerbation “in recognition of the enormous importance of COPD” in low and middle income countries.

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