31. Assessment of Symptoms
Best way to assess symptoms is to use validated questionnaires:
Modified Medical Research Council dyspnea scale. MMRC
COPD Assessment Test CAT
40. A diagnosis of COPD is based on the presence of symptoms and
obstruction demonstrated by a post-bronchodilator forced expiratory
volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of less
than 0.7 on spirometry.
The degree of FEV1 impairment, expressed as a percentage of the
predicted value, is used to determine the GOLD stage (1 to 4).
41. The severity of symptoms as determined by the Modified Medical
Research Council breathlessness score [mMRC] or the COPD
Assessment Test [CATTM]) and
The risk of exacerbations (based on the number of moderate or
severe exacerbations in the previous year) are used to determine
patient’s GOLD group (A to D).
42.
43.
44.
45.
46.
47.
48. COPD Goals of Therapy
48
Reduce Symptoms
Relieve symptoms
Improve exercise tolerance
Improve health status
Reduce Risk
Prevent disease progression
Prevent and treat exacerbations
Reduce mortality
GOLD 2017
61. Treatment algorithms GOLD 2019
The latest iteration of the GOLD treatment algorithms has changed
dramatically from 2017.
GOLD still uses the Refined Assessment Tool that was introduced in 2017 to
categorise COPD into four groups (A, B, C and D) based on symptoms and risk
of exacerbations .
Although it continues to use FEV1 to grade severity, this is not part of the
assessment tool.
63. The 2019 report emphasises that this assessment of symptom
severity & exacerbation risk is recommended only as a basis for
determining initial therapy and is not designed for reassessing
patients during follow up.
64. The 2019 report clearly separating recommendations for initial therapy
(which have now been simplified), from recommendations about how to
escalate or de-escalate therapy based on changes in the patient’s
breathlessness or exacerbation frequency.
71. Initial pharmacotherapy
The updated guidelines continue to recommend the utilization of the
ABCD assessment tool for the initial treatment of COPD, but no longer
recommend its use to adjust treatment thereafter.
There are two separate algorithms, one for initiation of therapy and
another for follow-up treatment
72. Initial pharmacotherapy
The 2019 report continues to recommend that patients are diagnosed
and assessed as described in the 2017 version.
The Initial treatment is based upon which of the four groups the patient
falls into at diagnosis
The treatment options in each group have been greatly simplified since
2017.
73. According to the GOLD 2019 Global Strategy for the Diagnosis, Management,
and Prevention of COPD guideline update, first-line pharmacologic therapy
depends on the patient’s GOLD group classification (A, B, C, D).
The GOLD 2019 guidelines do not include the preferred treatment algorithm.
Short-acting bronchodilators (short-acting muscarinic antagonist [SAMA] or
short-acting inhaled beta2 agonist [SABA]) should be prescribed to all patients
for immediate symptom relief, regardless of their GOLD classification.
75. For Group A patients, a short- or long-acting bronchodilator (long-acting
muscarinic antagonist [LAMA] or long-acting beta2 agonist [LABA]) is
recommended based on their effects on patients’ breathlessness.
(depending on the intensity and frequency of symptoms).
Group A
77. Initial therapy should consist of a long acting bronchodilator (LABA or
LAMA).
For Group B patients, the guidelines do not recommend one class of
long-acting bronchodilator over another for initial symptoms.
Initial therapy with two long-acting bronchodilators may be considered in
patients who are experiencing severe breathlessness on monotherapy.
Group B
79. For patients classified in Group C,initial therapy should consist of a single
long-acting bronchodilator.
LAMAs are superior to LABAs regarding COPD exacerbation prevention ,
therefore we recommend starting therapy with a LAMA in this group.
Group C
81. In general, therapy can be started with a LAMA as it has effects on both
breathlessness and exacerbations.
In Group D, a LAMA/LABA combination can be chosen as initial
treatment in patients experiencing more severe symptoms, such as
greater dyspnea and/or exercise intolerance (order of magnitude of
CAT™ ≥ 20) .
Group D
82. The 2019 guideline update recommends a LABA/ICS combination for
initial treatment in some patients with an eosinophil count greater than
300 cells/µL or those with a history of asthma and COPD.
ICS may cause side effects such as pneumonia, so should be used as
initial therapy only after the possible clinical benefits versus risks have
been considered.
Group D
83. Bronchodilators are still the recommended initial treatment for patients
in groups A, B, and C.
The choice of initial therapy for patients in group D, who are both
symptomatic and at risk of exacerbations, depends on the intensity of
symptoms and may also be influenced by the blood eosinophil count.
84. If patients is in group D , A LAMA is the recommended initial therapy
unless the patient is highly symptomatic (e.g. CAT score >20), in which
case dual bronchodilator therapy with a LAMA plus a long-acting beta
agonist is recommended.
If patients in group D have a blood eosinophil count of ≥300 cells/μl,
initial therapy with a LABA+ICS can also be considered.
85. The use of ICS is no longer recommended in GOLD Group C for initial
therapy.
ICS are only recommended for initial treatment in patients that fall into
Group D with elevated EOS count ≥ 300 cells/µL.
86.
87. The 2019 update focuses on using the ABCD assessment to determine
initial treatment only and then utilizing the management cycle to follow-
up and make changes to treatment.
The management cycle involves a three step process: review, assess, and
adjust, designed to treat COPD based on symptoms and exacerbations.
Recommendations at follow-up are no longer dependent on the patient’s
GOLD group (A, B, C, D) at diagnosis.
88. The guideline recommended three steps be conducted at each visit to
ensure appropriate management of COPD.
At each visit, a provider should:
1. Review symptoms
2. Assess inhaler technique, adherence and non-pharmacological
approaches (such as smoking cessation, pulmonary rehabilitation,
exercise training, etc.)
3. Adjust medications if needed.
89. If a patient’s current treatment achieves treatment goals, no changes in
treatment are recommended during assessment.
If the treatment is not optimized, consider therapy changes based on
separate dyspnea and exacerbation algorithms.
If a patient presents with both dyspnea and an exacerbation, the
exacerbation algorithm should be used.
90.
91. Follow-up treatment is now based on whether the patient has
continued breathlessness or frequent exacerbations but not on the
patient’s GOLD group at diagnosis (even though we can see that GOLD
grouping is actually based on symptoms and exacerbations).
92.
93.
94. FOLLOW-UP pharmacological treatment
Dyspnea
For patients with persistent breathlessness or exercise limitation
on long acting bronchodilator monotherapy, the use of two
bronchodilators is recommended.
If the addition of a second long acting bronchodilator does not
improve symptoms, we suggest the treatment could be stepped
down again to monotherapy.
Switching inhaler device or molecules can also be considered.
95. FOLLOW-UP pharmacological treatment
Dyspnea
For patients with persistent breathlessness or exercise limitation on LABA/ICS
treatment, LAMA can be added to escalate to triple therapy.
Alternatively, switching from LABA/ICS to LABA/LAMA should be considered
if the original indication for ICS was inappropriate (e.g., an ICS was used to
treat symptoms in the absence of a history of exacerbations), or there has
been a lack of response to ICS treatment, or if ICS side effects warrant
discontinuation.
96. FOLLOW-UP pharmacological treatment
Dyspnea
At all stages, dyspnea due to other causes (not COPD) should be investigated
and treated appropriately.
Inhaler technique and adherence should be considered as causes of
inadequate treatment response.
100. FOLLOW-UP pharmacological treatment
Exacerbations
For patients with persistent exacerbations on long acting bronchodilator
monotherapy, escalation to either LABA/LAMA or LABA/ICS is
recommended.
LABA/ICS may be preferred for patients with a history or findings suggestive
of asthma.
Blood eosinophil counts may identify patients with a greater likelihood of a
beneficial response to ICS.
101. FOLLOW-UP pharmacological treatment
Exacerbations
For patients with one exacerbation per year, a peripheral blood level ≥ 300
eosinophils/µL identifies patients more likely to respond to LABA/ICS
treatment.
For patients with ≥ 2 moderate exacerbations per year or at least one severe
exacerbation requiring hospitalization in the prior year, LABA/ICS treatment
can be considered at blood eosinophil counts ≥ 100 cells/µL, as ICS effects
are more pronounced in patients with greater exacerbation frequency and/or
severity.
102. FOLLOW-UP pharmacological treatment
Exacerbations
In patients who develop further exacerbations on LABA/LAMA therapy we
suggest two alternative pathways.
Blood eosinophil counts < 100 cells/µL can be used to predict a low
likelihood of a beneficial ICS response:
1) Escalation to LABA/LAMA/ICS. A beneficial response after the addition of
ICS may be observed at blood eosinophil counts ≥ 100 cells /µL, with a
greater magnitude of response more likely with higher eosinophil counts.
2) Add roflumilast or azithromycin if blood eosinophils < 100 cells/µL.
104. For the first time, GOLD has introduced the use of blood eosinophil count as a circulating
biomarker to help guide treatment choice.
105. Eosinophilic airway inflammation is present in a subset of patients with COPD
and blood eosinophil counts have been used as a practical biomarker of
eosinophilic airway inflammation in patients with COPD.
Studies have shown that blood eosinophil counts are not reliable as predictors of
the risk of exacerbations, but analysis of recent clinical trials has shown that
eosinophil counts are consistently predictive of the efficacy of ICS in
exacerbations.
Low eosinophil counts are predictive of a higher risk of developing pneumonia.
106. FOLLOW-UP pharmacological treatment
Exacerbations
►If patients treated with LABA/LAMA/ICS who still have exacerbations the
following options may be considered:
Add roflumilast. This may be considered in patients with an FEV1 < 50%
predicted and chronic bronchitis, particularly if they have experienced at least
one hospitalization for an exacerbation in the previous year.
Add a macrolide. The best available evidence exists for the use of azithromycin,
especially in those who are not current smokers.
Consideration to the development of resistant organisms should be factored into
decision-making.
107. FOLLOW-UP pharmacological treatment
Exacerbations
In patients who develop further exacerbations on LABA/ICS therapy, we
recommend escalation to triple therapy by adding a LAMA.
Alternatively, treatment can be switched to LABA/LAMA if there has
been a lack of response to ICS treatment, or if ICS side effects warrant
discontinuation .
108. De-escalation of treatment
De-escalation strategies are currently limited to patients who are taking ICS.
De-escalation of ICS can be considered if:
1. The patient experiences pneumonia
2. There was an inappropriate indication for the ICS when they were first prescribed
3. There was a lack of response (i.e. no change in the frequency of exacerbations
following the introduction of ICS therapy).
De-escalation may also be considered in patients with COPD receiving treatment
who return with resolution of some symptoms that subsequently may require less
therapy.
109. De-escalation of treatment
For patients who have had their treatment de-escalated, it is important to
monitor them under close medical supervision to ensure they do not
deteriorate as a result of the changes.
A blood eosinophil count ≥ 300 cells /µL identifies patients with the greatest
likelihood of experiencing more exacerbations after ICS withdrawal and who
subsequently should be followed closely for relapse of exacerbations.
"Spirometry remains a key diagnostic feature and an important modality in defining severity of airflow obstruction," Dr Martinez
told Medscape Medical News. "Therapeutically, it has limited relevance for pharmacotherapeutic options
