GOLD places greater emphasis on non-pharmacological approach

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has updated its strategy for the diagnosis, management and prevention of COPD, reinforcing the role for non-pharmacological treatment.

GOLD board member Professor David Halpin, a UK respiratory physician,  says the 2020 revision champions a more holistic approach to the management of COPD, highlighting that non-pharmacological approaches are as, if not more, important than pharmacological treatment for overall patient management.

“We’ve introduced a new overall summary of the diagnosis, assessment and treatment of COPD (Figure 4.1) that places equal emphasis on non-pharmacological and pharmacological management and encapsulates the current holistic view of COPD management,” Professor Halpin, a consultant respiratory physician at the Royal Devon and Exeter Hospital, UK, told the limbic.

“This builds on what we emphasised last year (which was the separation of initial assessment and pharmacological treatment from subsequent pharmacological treatment) in that we’ve applied the same sort of approach to the non-pharmacological treatment,” he said.

“We’ve separated initial non-pharmacological management from non-pharmacological interventions you would consider at review (such as pulmonary rehabilitation), suggesting that the need for these and response to them are reviewed in the same way that you would for pharmacological treatment.

“The non-pharmacological approach now mirrors the pharmacological approach.”

According to Professor Halpin, the 2019 revisions to the management of COPD have on the whole been well received, despite some challenges in following the algorithm for the follow-up changes to pharmacotherapy.

“I think clinicians accept that this is an attempt to move towards personalised medicine and that if you do that then the algorithms have to be slightly more complex, he said.

More important changes

While he agreed that the latest revisions are perhaps not as dramatic as those introduced last year, Professor Halpin says there are a couple of other important changes.

The section on exacerbations has been updated to clarify the diagnosis of exacerbations by describing relevant alternative diagnoses (Table 5.1). It notes that as other comorbidites that may worsen respiratory symptoms are common in COPD patients, clinical assessment to rule out differential diagnoses should be considered as part of the diagnosis of a COPD exacerbation.

Some more information has been added regarding the role of eosinophils as a biomarker for the efficacy of inhaled corticosteroids (Figure 3.1).

GOLD now no longer refers to Asthma-COPD overlap (ACO), instead emphasising that asthma and COPD are different disorders, although they may share some common traits and clinical features.

Professor Halpin says that unlike the Global Initiative for Asthma (GINA) which still believes the overlap concept is important, GOLD feels that clinicians should try very hard to differentiate asthma and COPD and use other indicators for when inhaled corticosteroids are indicated.

“We realise that may be difficult but we feel that the concept of an overlap syndrome is not very helpful, particularly as in COPD we now have biomarkers such as eosinophils and exacerbation history which are much better guides as to who needs inhaled corticosteroids rather than just saying ‘features of asthma’.”

For the first time, the 2020 update briefly acknowledges that inhaled respiratory medications may have a positive effect on all-cause mortality in people with COPD.

Professor Halpin said: “Studies in the past have suggested there may be a mortality benefit with COPD pharmacotherapy but have not been conclusive. We’ve put in something this time because we believe there is now accumulating evidence that treatment can affect mortality.

“We’re going to say more about it next year, but have begun to address it; I think it’s a really important message for patients and specialists that not only do these treatments make a difference to symptoms but they may have an impact on mortality.”

GOLD and NICE on the same page

According to Professor Halpin, the GOLD 2020 update and recent NICE guidance on diagnosing and managing COPD are complementary, with the exception of one minor difference.

“In GOLD we still recommend starting with single long acting bronchodilator therapy first and then increasing to dual if necessary; NICE goes straight for dual bronchodilator therapy.”

However, he believes GOLD offers much more useful, practical information on how to manage patients that is much easier for clinicians to follow and implement in practice.

He is also critical of the new recommendations on inhaled triple therapy that NICE added to its guidance in July this year, noting that the suggestion to trial triple therapy for only three months is unhelpful.

“The benefits of triple therapy are to prevent exacerbations, but how would you know whether you’ve prevented an exacerbation in three months?”

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