New 2017 GOLD Guidelines for COPD Released

Review Articles, Clinic and Consults, COPD Add Comments

Dec

072016

The Global Initiative for Obstructive Lung

Disease(GOLD - because GIOLD sounded weird) is an international collaboration of
experts in chronic obstructive pulmonary disease (COPD). Every so often the GOLD
gang releases another update of their standard-setting GOLD guidelines. (Read
PulmCCM's 2014 GOLD guideline review and ourCOPD Review.)
Get the full 2017 GOLD guidelines or the 36 page "pocket" review on the GOLD
website for the important details. Following are PulmCCM's take on some of the GOLD
2017 highlights.
COPD Severity: GOLD 2017 Guidelines
GOLD continues to refine its ABCD grading system, introduced in 2011, to determine
the severity of COPD. The ABCD grading system considers COPD symptoms along with
exacerbation frequency and severity (A is better, D is worse).
Airflow limitation is not a component of the ABCD system. Spirometry remains
important mainly for diagnosis, prognosis and consideration of therapies. Why is
spirometry not part of the severity grading system? Airflow limitation correlates less
well with functional limitation and quality of life than do patient reported symptoms and
history of COPD exacerbations.
COPD Treatment: GOLD 2017 Guidelines
Long-acting bronchodilators. Almost all patients with COPD who experience more
than occasional dyspnea should be prescribed long acting bronchodilator therapy. This
could be a long-acting beta agonist (LABA), a long acting muscarinic antagonist (LAMA),
or both. Patients with persistent COPD symptoms while taking one long-acting

bronchodilator should be prescribed two (or a combination agent containing two long
acting bronchodilators).
Inhaled corticosteroids are not recommended as monotherapy in COPD. Combination
agents containing inhaled corticosteroids along with long-acting beta agonists are
considered appropriate step-up therapy for patients experiencing COPD exacerbations
while taking long-acting bronchodilators.
Oral PDE4 inhibitors are considered an add-on therapy only for patients with COPD
with chronic bronchitis and severe airflow restriction who experience COPD
exacerbations despite use of a combination bronchodilator with inhaled corticosteroid.
Drugs for secondary pulmonary hypertension due to COPD are not advised.
Oxygen Not Recommended for Most COPD Patients in GOLD 2017
The 2017 GOLD guidelines generally advise against the routine practice of prescribing
supplemental oxygen to stable COPD patients without severe resting hypoxemia. In
a randomized trial in >700 stable COPD patients with moderate
hypoxemia, supplemental oxygen did not improve clinical outcomes or quality of life
during the followup period. The guidelines do suggest that
individual patient factors may be considered when evaluating a patient's need for
supplemental oxygen.
COPD patients with severe resting hypoxemia (oxygen saturation 88% and certain
other patients with COPD) should all receive supplemental oxygen to be worn
continuously.
The ABCDs of COPD Treatment in 2017 GOLD Guidelines
The 2017 GOLD guidelines go further in advising physicians exactly what class of
medication to use, in which COPD patients according to where they fall in the ABCD
grading scheme:
COPD GOLD Grade A: Any bronchodilator (short or long acting), titrating or switching
to another as appropriate.
COPD GOLD Grade B: A long acting bronchodilator (LAMA or LABA), and both if
symptoms persist on one drug.

COPD GOLD Grade C: A long acting muscarinic antagonist (LAMA), switching to

LAMA+LABA or to LABA+ICS if further exacerbations occur.
COPD GOLD Grade D: More complicated, requires individual management, often
multiple drugs, consideration of roflumilast and azithromycin in selected patients.
Inhaler technique should be demonstrated for all patients and technique confirmed
before concluding a medication is not working.
Non-Pharmacologic Treatment of COPD: GOLD 2017
The 2017 GOLD guidelines weigh in on numerous other aspects of the medical
management of COPD:

Pulmonary rehabilitation (recommended for patients with severe symptoms or

frequent exacerbations)

Exercise (for all patients)

Vaccination against influenza (all COPD patients) and pneumococcus (all COPD
patients older than 65 or with other cardiopulmonary disease)

Daily oral opioids for severe COPD symptoms refractory to medical therapy

Palliative care

Other stuff
And The Winner of GOLD 2017 is ... Pharma?

The 2017 GOLD guidelines reflect improvements in COPD therapies and the latest
evidence from multiple large randomized trials, and all this should help patients. But
GOLD 2017 also represents a big win for makers of the next-generation combination
inhaler treatments.
The GOLD recipe for treatment of COPD guides physicians through a cakewalk of
recommended drug classes. Although specific drugs aren't advised, the GOLD path
through Grade B and C (i.e., most of the 11 million people living with COPD in the U.S.)
advises dual therapy with a LABA and LAMA.
A busy physician can prescribe two inhalers requiring two different techniques,
explanations, copayments, with increased likelihood of nonadherence -- or simply write
for a once daily combination LAMA+LABA inhaler. At this writing, that's two drugs:

Stiolto Respimat (tiotropium bromide and olodaterol), Boehringer Ingelheim

Anoro Ellipta (umeclidinium bromide/vilanterol), GSK

Bevespi Aerosphere (glycopyrrolate and formoterol) from AstraZeneca and Utibron

Neohaler (indacaterol and glycopyrrolate) by Novartis are twice daily combination
LAMA/LABA inhalers.
Also available are single agent LABAs formoterol, salmeterol, indacaterol, olodaterol;
LAMAstiotropium, glycopyrrolate, aclidinium, and more. The GOLD 2017 at a glance
guide provides a handy table of COPD bronchodilator inhaler treatments.
Once-daily combination inhalers for COPD will likely result in better adherence, which
could result in improved health outcomes compared to twice-daily regimens requiring
multiple devices. But the newest COPD combination inhalers aren't on all formularies
and will be out of financial reach for many patients. The 2017 GOLD guidelines are
grounded in reality on this point, emphasizing:
The choice of inhaler device has to be individually tailored and will depend on
access, cost, prescriber, and most importantly [the] patient's ability and preference.
In other words, the best inhaler for COPD is the one a patient can afford, understands,
agrees with and will use regularly.

SOURCE:
http://pulmccm.org/main/2016/copd-review/new-2017-gold-guidelines-copdreleased/