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Prof David Halpin
The 2019 update to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) strategy for the diagnosis, management and prevention of COPD is now available and includes two key changes, according to GOLD board member Professor David Halpin.
The first is that initial treatment, based on the ABCD assessment tool, has been separated from follow-up treatment based on the patient’s major treatable traits and their current treatment regimen.
Previous iterations of GOLD had brought some uncertainty around the appropriate use of the ABCD system, says Professor Halpin, a consultant respiratory physician at the Royal Devon and Exeter Hospital, UK.
In particular there was confusion as to whether ABCD applied only to initial therapy or also to subsequent therapy, he told the limbic in an interview.
“That’s why we’ve separated the two algorithms and why we’ve also included the management cycle about reviewing, assessing and adjusting,” he explains.
“You need to make the initial treatment choice based on where somebody is on the grid in ABCD, review how they’re responding, assess what’s contributing to that – very importantly remembering inhaler technique and non-pharmacological approaches – and if appropriate then change their medication in line with the escalation or de-escalation algorithms depending on whether you’re trying to treat breathlessness or exacerbations and what medication they are currently on.”
He says the committee has tried to emphasise the importance of non-pharmacological therapies and that the cycle of ‘review, assess and adjust’ should include all the classical things such as inhaler technique, compliance and thinking about non-pharmacological therapies.
“The clear separation of initial and subsequent therapy is one really big change in GOLD,” he says.
The other change is the introduction of the blood eosinophil count as a biomarker for estimating the efficacy of inhaled corticosteroids (ICS) for the prevention of exacerbations.
“The evidence that blood eosinophil counts can help guide treatment choices has now reached a point where we felt it should be included in the management strategies.
“So both in terms of choice of initial therapy, when you might use a LABA plus ICS in group D, and then in terms of escalation when choosing between different options, particularly between dual bronchodilators and triple therapy or LABA plus ICS, using blood eosinophil counts together with the frequency of exacerbations to help guide what seems the most appropriate therapy,” Professor Halpin says.
2018 update issues addressed
Professor Halpin thinks the update addresses at least some concerns about the 2018 GOLD COPD update raised by clinicians and researchers from the Mayo Clinic, US, in a review published in Mayo Clinic Proceedings last month.
The team critiqued some parts of the 2018 report, including the issue of a fixed FEV1/FVC ratio for diagnosis and the ABCD classification.