Latest GOLD: ‘clear separation of initial & subsequent therapy’


By Jennie James & Mardi Chapman

26 Nov 2018

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.

“The changes address some of the points that they raised about how you sequence treatment and clarify the point that what we said previously was initial therapy based on ABCD and then escalation was more complex. I think we’ve tried to make that more explicit now,” Professor Halpin says, conceding that the controversy continues over the fixed ratio.

He notes there is an important change to the 2018 update that might have slipped through unnoticed – and is again included in the new update. This is the recommendation that if the FEV1/FVC ratio is close to 0.7 when assessing whether a patient has airflow obstruction, the assessment should be repeated before concluding whether a patient is obstructed or not. This is because there is evidence of some variability particularly if the ratio is close to 0.7.

Australian perspective

Prof Peter Frith

Professor Peter Frith, a co-author of the GOLD update, told the limbic he agreed with his UK colleague’s summary of the key changes.

“I would add that the GOLD Statement provides guiding principles that can be adapted for use in any country of the world, although it is increasingly acknowledging that the availability of diagnostic and therapeutic tools varies widely between countries.”

“Some of the drugs mentioned in GOLD, for example, are not available through PBS in Australia, and availability of pulmonary rehabilitation is regrettably patchy.”

Most practitioners in Australia – GPs and specialists – tended to follow the evidence-based COPD-X Guidelines, said Professor Frith, of Flinders Medical Centre, Adelaide.

“These Guidelines do not use the GOLD ABCD approach, but have for some time provided guidance for diagnosis, emphasising the critical role of spirometry and supporting the same criteria as GOLD.”

“COPD-X next guides assessment of the individual patient to address the same patient characteristics as GOLD – FEV1 to understand the long-term risk of all-cause and respiratory mortality; symptoms, including breathlessness, cough, sputum, wheeze, etc, which then becomes a target for initiating symptom-reduction therapies; and exacerbation history, which then becomes a target for initiating therapies that reduce the risks for future exacerbations.”

“COPD-X also has its ’Stepwise Guide’ for initiating and changing therapy based on these assessment principles at first patient contact and at follow-up assessments, with switching, stepping up and stepping down therapies according to progress,” he said.

He added COPD-X emphasises both the importance of ensuring correct inhaler technique and minimising the numbers of different inhaler devices for the individual patient, and the possibility that poor symptoms control might be due to other chronic conditions that often occur as comorbidities with COPD.


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