GOLD 2023 – exploring the GOLDen ideas of this year’s report

Every year we hear about the latest strategy and report from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) and notice how it changes. This seems to create debate.

From what I hear, I believe that most of the discussions tend to be centred on prescribing, though the report contains a much wider perspective on the diagnosis and care of those with chronic obstructive pulmonary disease (COPD).

It is worth initially highlighting that the report is not pretending to be a guideline – though again I often hear it quoted as such.

Guideline production and development has been happening since the 1990s,^[1],[2],[3] and although the production of the evidence base and its robustness has developed since that time, the principles remain very similar.^[4]

In my view, GOLD does not have a clinical and patient input that would mean it could be deemed appropriate to be a guideline. GOLD does however have some very influential and experienced clinicians and academics involved and does base its recommendation on the literature. GOLD is also designed for use at a global level, rather than specifically being developed for one country or health care system.

In this article, I will try and highlight some of the recommendations that GOLD make – and detail how these may differ to others in the field. You can use the links below to jump to a section that interests you, or read on to explore the recommendations in full.

• Diagnosing COPD
• Exacerbations
• Monitoring
• Vaping and e-cigarettes: controversy
• Prevention and maintenance therapy

Diagnosing COPD

 GOLD recommend that good quality spirometry should be used to help confirm the diagnosis of COPD.^[5] It also reiterates that it is valuable to make the diagnosis, assuming history, examination and basic investigations are also supportive of it.^[5]

GOLD, however, recommend that the diagnosis is based on a fixed ratio of forced expiratory volume in 1 second (FEV₁)/forced vital capacity (FVC) being less than 70%.^[5]

Others, such as the National Institute for Clinical Excellence (NICE),^[6] the Primary Care Respiratory Journal (PCRJ),^[7] the American Thoracic Society (ATS) / European Respiratory Society (ERS),^[8] and more recently The Association for Respiratory Technology & Physiology (ARTP),^[9] suggest a more nuanced interpretation based on the lower limit of normal readings. This recognises that the ratio does not remain the same throughout our lives, and can result in overtreatment.

GOLD suggest there is limited evidence of harm in those who are overtreated and that it is easier for all (globally) to use the fixed ratio.^[5] It would appear to be clear that in the UK, guidance supports the more nuanced approach, and we should encourage our clinicians to be aware of the potential hazards and seek more expert help if unclear.^[6],[7]

GOLD do remind us of using up-to-date lung function parameters, for example Global Lung Initiative (GLI) to ensure good interpretation.^[5]

Unlike NICE in the UK, and other bodies in the US, GOLD do not recommend blanket screening of populations in its recommendations^[5],[10] but do recommend case finding in populations with:^[5]

• more than 20 pack years of smoking
• recurrent chest infections
• early life respiratory events.

GOLD suggest at diagnosis that severity is now categorised into three groups, evolved from the previous ABCD grouping, to the new A, B and now, E.^[5]

Group A is patients with no symptoms and no exacerbations – which it could be argued, if someone has no symptoms and no exacerbations, do they really have COPD?  If they do, they should be, as a part of basic care, encouraged to be active and fitter which would inevitably produce symptoms as they improve, hence this category may be confusing.^[5]

Group B is patients with symptoms but no exacerbations – though much of the longitudinal research suggests that it is only a matter of time before a patient has an exacerbation.^[5]

Group E is those patients who exacerbate (two out of hospital, or one in hospital exacerbation). This is difficult to identify at the time of diagnosis, as few hospital units perform spirometry whilst making that new diagnosis. This means we are having to suggest that exacerbations are diagnosed retrospectively after a diagnosis is made (with the inherent assumptions and dangers in this).^[5]

Exacerbations

GOLD continue to support the concept of mild, moderate, and severe exacerbations with:^[5]

• mild being fluctuation in symptoms requiring increased short-acting bronchodilators only
• moderate, requiring short-acting bronchodilators and steroids ± antibiotics
• severe, requiring hospital admission.

There is certainly strong support for managing these carefully and trying to reduce subsequent exacerbations.^[6] However, when I discuss with colleagues across the UK, many patients who are admitted with a ‘severe exacerbation’, the actual severity is found to be not so severe, but anxiety and lack of care in the community contribute to an increase sense of severity. Similarly, many patients with ‘moderate exacerbations’ have similar severity to in-hospital exacerbations. This is of course anecdotal evidence, but non-invasive ventilation is not suitable for all patients with respiratory failure.^[11]

Monitoring

GOLD continue to recommend the use of BODE for COPD monitoring.^[5] BODE stands for Body mass index, degree of Obstruction with FEV₁, extent of Dyspnoea with modified Exercise tolerance.

As FEV₁ monitoring can be performed quickly and easily in many environments, we should encourage this form of monitoring to detect deterioration. Another well-validated tool to monitor and assess risk is the DOSE index.^[12] This stands for Dyspnoea with Medical Research Council (MRC) scale, Obstruction, Smoking status and Exacerbations.^[12] Whichever model you use, detailed monitoring and looking wider can be good for improving patient care.

Vaping and e-cigarettes: controversy

Somewhat controversially, GOLD do not recommend use of vaping or e-cigarettes based on lack of evidence, seemingly suggesting we wait and collect evidence before making a decision.^[5]

This is different to Public Health England, who have adopted an evaluation of theoretical evidence suggesting that many of the carcinogen and thrombotic chemicals that have been identified in smoking tobacco are at lower levels in vaping nicotine ^[13]. The Public Health England review does highlight vaping is not risk free, but supports vaping as of lower risk than tobacco smoking in established smokers.^[13]

Prevention and maintenance therapy

GOLD recommend use of COVID as well as pneumococcal and influenza vaccination.^[5] GOLD recommend diphtheria, tetanus and pertussis (DTP) if this was not undertaken in childhood^[5] – we know that many who get whooping cough (pertussis) as adults can have quite a protracted illness as the vaccine efficacy diminishes.^[14] We should pay more attention to whooping cough in those with chronic respiratory disease.^[15],[16]

GOLD also recommend some areas that are undertaken variably in the UK. This includes avoiding intravenous methylxanthines (theophylline or aminophylline) for COPD exacerbations, because of the risk of significant side effects.^[5] GOLD suggest that all admitted to hospital with COPD should have Vitamin D levels checked to look for severe deficiency.^[5] This is supported by a metanalysis which found that in those who have a low Vitamin D level (less than 25nmol/l), supplementation safely and substantially reduced the rate of moderate / severe COPD exacerbations.^[17]

GOLD also suggest a review after an exacerbation at 1-4 weeks and at 12-16 weeks to review our patients specifically looking at checking medicines and inhaler technique along with oxygen requirements.^[5]

GOLD are very supportive of pulmonary rehabilitation, good nutrition, smoking cessation and consideration if appropriate for surgical interventions.^[5] They also provide some global recommendations on identifying and managing associated potential long term conditions like cardiac disease, osteoporosis and mental health problems which are gaining more prominence.^[5]

Conclusion

In conclusion, the GOLD report is a useful contribution to the literature and thinking on COPD – and should challenge us to consider whether our own national guidelines remain fit for purpose and are robust enough to deliver the care that is required.

It is a lot more than just recommendations on which drug groups to use – and is aimed at a global level with a more specialised orientation. Perhaps when you have the odd hour or so, have a look at some of the other areas covered and see if they fit in with your expectations.

Any advice given and opinions expressed in this article are those of the author and do not reflect the view of Chiesi Limited (Chiesi).  All content in this article is for informational and educational purposes only.  Although Chiesi strives to always provide accurate information, it is not responsible for and does not verify for accuracy any of the information contained within.

[1] Shekelle P, Woolf S, Eccles M, et al. Clinical guidelines: developing guidelines. BMJ. 1999: 318.

[2] Rawlins MD. National Institute for Clinical Excellence: NICE works. J R Soc Med. 2015; 108(6): 211-219.

[3] Graham I, Beardall S, Carter A, et al. What is the quality of drug therapy clinical practice guidelines in Canada? CMAJ. 2001; 165(2): 157-63

[4] Grol, R, Cluzeau, FA, & Burgers, JS. Clinical practice guidelines: towards better quality guidelines and increased international collaboration. British Journal of Cancer. 2003; 89(1), S4-S8.

[5] Global Initiative for Chronic Obstructive Lung Disease. 2023 Gold Report. Available at: https://goldcopd.org/2023-gold-report-2/

[6] National Institute for Clinical Excellence. NG 115 Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: https://www.nice.org.uk/guidance/ng115

[7] Levy M, Quanjer P, Booker R, et al. Diagnostic Spirometry in Primary Care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Resp J. 2009 ;18(3): 130-47.

[8] Miller M, Hankinson J, Brusasco V, et al. Standardisation of spirometry. Eur Respir J. 2005; 26(2): 319-38.

[9] Pagano L, Dennis S, Wootton S, et al. Identifying airway obstruction in primary care: is there a role for physiotherapists? BMC Prim Care. 2022; 23: 324, 1-9.

[10] Webber E, Lin J, Thomas R. Screening for Chronic Obstructive Pulmonary Disease Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA. 2022; 327(18): 1812-6.

[11] British Thoracic Society Standards of Care Committee. Non-invasive ventilation in acute respiratory failure. Thorax. 2002; 57(3): 192-211.

[12] Jones R, Donaldson G, Chavannes N, et al. Derivation and validation of a composite index of severity in chronic obstructive pulmonary disease: the DOSE Index. Am J Respir Crit Care Med. 2009; 180(12): 1189-95.

[13] Office for Health Improvement & Disparities. Nicotine vaping in England: 2022 evidence update summary. Available at: https://www.gov.uk/government/publications/nicotine-vaping-in-england-2022-evidence-update/nicotine-vaping-in-england-2022-evidence-update-summary

[14] Moore A, Ashdown H, Shinkins B, et al. Clinical characteristics of pertussis-associated cough in adults and children: a diagnostic systematic review and meta-analysis. Chest. 2017; 152(2): 353-67.

[15] Blasi F, Bonanni P, Braido F, et al. The unmet need for pertussis prevention in patients with chronic obstructive pulmonary disease in the Italian context. Human Vaccines & Immunotherapeutics. 2020; 16(2): 340-8.

[16] Jenkins V, Savic M, Kandeil W. Pertussis in high-risk groups: an overview of the past quarter-century. Human vaccines & immunotherapeutics. 2020; 16(11): 2609-17.

[17] Jolliffe D, Greenberg L, Hooper R, et al. Vitamin D to prevent exacerbations of COPD: systematic review and meta-analysis of individual participant data from randomised controlled trials. Thorax. 2019; 74(4): 337-45.