Neil Skolnik, MD
January 06, 2023
I’m Dr Neil Skolnik. Today we are going to talk about the 2023 GOLD guide for COPD.
The big news here is a more streamlined approach to treatment, combining what used to be categories C and D into one category — E — for exacerbations. There is continued emphasis on getting a CBC with differential to assess the level of eosinophils to help guide decisions about when to use inhaled corticosteroids (ICS).
Let’s start with screening for COPD. So we are clear, screening is not recommended. But we should have a low threshold for using spirometry as a diagnostic test because that’s how you make the diagnosis of COPD, by demonstrating non–fully reversible airflow obstruction with a post-bronchodilator FEV1/FVC of < 0.7. Spirometry also establishes the severity of airflow limitation, as defined by the percentage of predicted post-bronchodilator FEV1. This defines the stage of COPD from stage 1 to stage 4.
Treatment decisions, however, are not based on spirometry or stage of airflow obstruction but rather on treatable traits — those traits being symptoms and risk for and history of exacerbation. Symptom burden and the history of exacerbations drive treatment decisions. Severe exacerbations are defined as having required an emergency department (ED) or hospital admission. Moderate exacerbations are those that require systemic steroids and/or antibiotics but not an ED or hospital admission.
The main treatment goals are reduction of symptoms and the future risk for exacerbations.
Let’s simplify treatment. There are basically two types of inhalers for COPD: bronchodilators and anti-inflammatory inhalers. Bronchodilators are either LAMAs (long-acting muscarinic antagonists) or LABAs (long-acting beta agonists). Anti-inflammatory inhalers are ICS.
The big change in the 2023 guidance is that the old A-B-C-D algorithm that we have been hearing about for years (with high exacerbation risk categories C and D being distinguished by the degree of symptoms) is out. In its place is a more streamlined algorithm for patients naive to therapy, with groups A, B, and E.
Groups A and B represent patients with very few exacerbations — one or fewer moderate exacerbations and no COPD-related hospitalization. Group E includes patients who have had significant exacerbations — two or more moderate exacerbations requiring systemic steroids and/or antibiotics, or a hospitalization or ED visit for a COPD exacerbation. Patients in group A have relatively mild symptoms, and a bronchodilator is recommended. Patients in group B have a higher symptom burden and it is recommended to start with dual bronchodilator therapy.
I personally wouldn’t struggle over this one. The American Thoracic Society says dual-bronchodilator therapy is recommended as initial therapy because it gives better bronchodilation with no significant increase in risk. Also, if you choose to start with a single bronchodilator and the patient is still having symptoms, then you bump up to dual bronchodilator therapy.
For those in group E, who are at elevated risk for future exacerbations, the guidelines recommend starting with dual bronchodilator therapy. If blood eosinophil counts are > 300 cells/µL, then consider starting triple therapy with a LABA, LAMA, and ICS.
Next, recommendations are made for follow-up therapy. If the patient still has symptoms of shortness of breath while on only a single bronchodilator, then increase to dual-bronchodilator therapy. That’s simple. If the patient has exacerbations on single bronchodilator therapy, with an eosinophil count < 300 cells/µL, increase to dual-bronchodilator therapy. If the eosinophil count is > 300 cells/µL, or if the patient is already on dual therapy and the eosinophil count is > 100 cells/µL, escalate to triple therapy with a LABA/LAMA/ICS inhaler.
Roflumilast and azithromycin are mentioned as treatments for those with severe COPD and eosinophil counts < 100 cells/µL who are on dual therapy, or for select patients on triple therapy who are still having exacerbations.
If I had to summarize this in a sentence, I’d say don’t hesitate to use dual-bronchodilator therapy in patients with significant symptoms, and don’t hesitate to escalate to triple therapy if patients have a significant exacerbation burden, meaning two or more outpatient exacerbations or even a single hospital-level exacerbation.
Other recommendations include the critical importance of smoking cessation and vaccination for COVID, influenza, pneumococcal disease, and pertussis (dTaP/dTPa) as well as zoster for patients over 50 years old, and an emphasis on the importance of exercise, activity, pulmonary rehabilitation, and oxygen therapy for patients with severe resting chronic hypoxemia.
These are important new recommendations that help simplify our treatment approach and can make a big difference for our patients.
I’m Neil Skolnik, and this is Medscape.
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