New 2017 GOLD Guidelines for COPD Released
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 our COPD 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 (obstruction on spirometry) is not a component of the ABCD severity 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.
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
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; LAMAs tiotropium, 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.