News
GOLD COPD report: 2023 update
Justin Curtis
Published Online
November 30, 2022
https://doi.org/10.1016/
S2213-2600(22)00494-5
For the GOLD COPD 2023 report
see https://goldcopd.org/2023-
gold-report-2/
The 2022 GOLD International
COPD conference was hosted
virtually and live by the Temple
Lung Center on Nov 16, 2022, at
the Sheraton Philadelphia
Downtown hotel (Philadelphia,
PA, USA). https://www.
goldcopdconference.com/event/
e96775f0-fbea-491c-8bf7-
743b595fa2f9/summary
18 www.thelancet.com/respiratory Vol 11 January 2023
On Nov 14, 2022, the Global Initiative
for Chronic Obstructive Lung
Disease (GOLD) published their 2023
global strategy for the diagnosis,
management, and prevention of
chronic obstructive pulmonary disease
(COPD). Highlights from the 2023
report were presented at the 2022
GOLD International COPD conference.
Some of the key changes in the 2023
report include a revised definition of
COPD: “COPD is a heterogeneous lung
condition characterized by chronic
respiratory symptoms (dyspnea, cough,
sputum production, exacerbations)
due to abnormalities of the airways
(bronchitis, bronchiolitis) and/
or alveoli (emphysema) that cause
persistent, often progressive airflow
obstruction.” Additionally, a table has
been added with proposed taxonomy
for classification of etiotypes of COPD.
Nirupama Putcha (Johns Hopkins
University School of Medicine,
Baltimore, MD, USA) commented “The
new definition of COPD appropriately
emphasises the heterogeneous nature
of the disease. The classification of
individuals into “etiotypes” recognises
the interplay between susceptibility,
exposures, and life course, although
the relevance of these to diagnostic and
treatment strategies remains unclear.”
Chapter 1 of the report also
highlights new opportunities to
diagnose COPD earlier and treat
appropriately. It describes some
individuals who present with structural
lung lesions and physiological
abnormalities without airflow
obstruction who are categorised
as having the pre-COPD precursor
condition. However, Tobias Welte
(Hannover Medical School, Hannover,
Germany) commented “There are two
main phenotypes of COPD (airway
inflammation and emphysema),
which could be different in clinical
symptomatology, but also [in] lung
function alterations. Even with a
normal FEV1/FVC ratio without airway
obstruction COPD can be present when
this is confirmed by other findings (ie,
chest radiology). In some [instances]
this could be the case in advanced
disease.”
In chapter 2 on diagnosis and
assessment, the previous ABCD patient
Assessment Tool for initial assessment
and initiation of pharmacological
management of COPD has been
changed to the ABE Assessment Tool.
Groups A and B are unchanged, but
groups C and D have been merged
into a single group E to highlight the
clinical relevance of exacerbations.
Patients categorised as group A have
modified Medical Research Council
(mMRC) dyspnoea scale scores of
0–1, a COPD Assessment Test (CAT)
score <10, and a history of zero or
one moderate exacerbation not
leading to hospitalisation. Patients
in group B have mMRC scores ≥2, a
CAT score ≥10, and a history of zero
or one moderate exacerbation not
leading to hospitalisation. Patients in
group E have a history of ≥2 moderate
exacerbations or ≥1 exacerbation
leading to hospitalisation, irrespective
of their mMRC or CAT scores. Welte
commented “The former C category
(exacerbations without symptoms)
was clinically not relevant; to combine
C and D with a focus on exacerbation
reflects the clinical situation.” Putcha
added “The change better aligns with
the presentation of patients in clinical
practice.”
In chapter 4 on the management
of stable COPD, new text has been
added that when initiating treatment
with long-acting bronchodilators, the
preferred choice is a combination of
a long-acting muscarinic antagonist
(LAMA) and a long-acting beta-agonist
(LABA); a high symptom burden of
dyspnoea persists in most patients
when using either a LAMA or LABA
alone. Additionally, it states that the use
of a LABA–inhaled corticosteroid (ICS)
combination should not be encouraged
in COPD. LABA–ICS has therefore been
removed from recommended initial
treatments, and LABA–LAMA should
be initiated for patients in groups B and
E. Putcha commented “The removal
of LABA–ICS from recommended
initial treatments and [a] more
targeted approach for ICS use is more
consistent with current evidence and
will hopefully lead to more judicious
use of ICS in COPD. The algorithm also
recommends considering LABA–LAMA–
ICS for patients in group E if blood
eosinophil counts are ≥300 cells per μL,
because of the positive effect of triple
treatment on mortality in this patient
subgroup. Welte commented “This
reflects the fact that corticosteroids
mainly are effective when eosinophilic
inflammation is present. The threshold
used here is conservative; there is a grey
area between 100 and 300 eosinophils
per μL where ICS might have a place
in some patients, however this needs
further evaluation.”
One final key change to the 2023
report is a new definition of a COPD
exacerbation. The previous definition
was considered too vague. The new
definition is: “an event characterised
by increased dyspnoea 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”. Welte commented
“This is a precision with regard to
the duration of increased symptom
before an exacerbation is diagnosed.
Only acute deterioration should be
called an exacerbation; long-term
increase in symptomatology should
be called disease progression. Putcha
added “The enhanced definition of
exacerbations of COPD emphasise the
timecourse and offers a systematic
framework for assessment and
diagnosis of exacerbations, including
a recommendation to understand the
cause of events.”
Priya Venkatesan