The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has released a 2023 guideline update on the management of Chronic Obstructive Pulmonary Disease (COPD)[1]. The prevalence rate of COPD in the Asia-Pacific is 6.2%, which is almost similar to the 6.7% rate in USA. By 2030, it is predicted to become the third leading cause of death world-wide [2]. The 2023 guideline updates contain significant changes in the definition of COPD and treatment recommendations, which will impact clinical practices. This article aims to summarise the key changes, for more in depth recommendations, refer to the full GOLD report here.
Definition of COPD
Changes have been made to the definition of COPD, emphasizing the key disease characteristics and heterogeneity of manifestations, etiopathology and structural abnormalities associated with it. A post-bronchodilator forced expiratory volume in 1 second / forced vital capacity (FEV1/FVC) of ≤0.7 via spirometry still remains as the key diagnostic criterion for COPD.
“Chronic Obstructive Pulmonary Disease (COPD) is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.”
The guidelines have also included new proposed taxonomy (etiotypes) of COPD, including non-smoking related etiotypes to highlight that tobacco smoking is not the sole cause of COPD.
Classification of COPD severity
ABCD Assessment Tool has been revised to ABE assessment tool to recognise the clinical relevance of exacerbations, independent of symptoms. The C and D groups are merged into a single group “E”, which will include patients with a history of either two or more moderate exacerbations or any severe exacerbation (defined as one requiring hospitalization) in the previous year.
Updates in treatment recommendations
Treatment recommendations for Group A remain the same. However, the recommendations for Group B has been changed from Long Acting beta2-agonists (LABA) or muscarinic antagonists (LAMA) to combination LABA+LAMA, based on a study by Maltais et al. showing that combination treatment compared to monotherapy provides early and sustained improvements in lung function and symptoms while also reducing the risk of deterioration or treatment failure in patients with low exacerbation risk without ICS. For patients already on existing long acting bronchodilator monotherapy with stable COPD, therapy can remain.
LABA + LAMA combination is recommended for patients categorised under Group E. A Cochrane systematic review and network meta-analysis comparing dual combination therapy versus mono long-acting bronchodilators showed that the LABA+LAMA combination was the highest ranked treatment group to reduce COPD exacerbations. If eosinophils ≥ 300 cells/μL, signifying high risk of exacerbations, consider LABA+LAMA+ICS.
Blood eosinophil count can predict the effect of ICS in preventing future exacerbations when added on to maintenance bronchodilator treatment. No and/or small effects are observed at lower eosinophil counts, with incrementally increasing effects observed at higher eosinophil count. The threshold of a blood eosinophil count ≥ 300 cells/μL identifies the top of the continuous relationship between eosinophils and ICS, and can be used to identify patients with the greatest likelihood of treatment benefit with ICS.
COPD patients with a concurrent diagnosis of asthma should be treated as per asthma.
New definition of COPD exacerbation
There is a new definition of COPD exacerbation within the GOLD 2023 guidelines to include specific symptoms and duration, with more objective clinical variables to define the severity of the exacerbation. This will help physicians to make timely decisions on treatment escalation.
“ An exacerbation of chronic obstructive pulmonary disease (ECOPD) is defined as an event characterized by increased dyspnea and/or cough and sputum that worsens in < 14 days which may be accompanied by tachypnea and/or tachycardia and is often associated with increased local and systemic inflammation caused by infection, pollution, or other insult to the airways”
Vaccinations in COPD
The vaccination recommendations have been updated to include COVID-19 vaccinations and new pneumococcal vaccines.
- All patients with COPD should receive COVID-19 vaccination in line with national recommendations
- Patients with COPD should receive 1 dose of 20 valent pneumococcal conjugate vaccine (PCV20); or one dose of 15 valent pneumococcal conjugate vaccine (PCV15) followed by 23-valent pneumococcal polysaccharide vaccine (PPSV23). Pneumococcal vaccination has been shown to reduce incidence of community acquired pneumonia and exacerbation in patients with COPD
- Tdap vaccination (dTaP/dTPa; pertussis, tetanus and diptheria) is recommended to protect against pertussis for people with COPD not vaccinated during adolescence, and Zoster vaccine to protect against shingles for patients above 50 years old.
Conclusions
These guidelines have provided a simplified update with regards to the categorisation of COPD severity and treatment recommendations based on COPD severity. It is important that clinicians learn how to implement the latest updates into their clinical practice, to provide prompt diagnosis and provide the most appropriate interventions
References
- Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for Prevention, Diagnosis and Management of COPD: 2023 Report. https://goldcopd.org/2023-gold-report-2/
- Woo L, Smith HE, Sullivan SD. The economic burden of chronic obstructive pulmonary disease in the Asia-Pacific Region: A systematic review. Value in Health Regional Issues. 2019;18:121–31. doi:10.1016/j.vhri.2019.02.002
