From the Guidelines
GOLD E in COPD is managed with triple therapy consisting of an inhaled corticosteroid (ICS), a long-acting beta-agonist (LABA), and a long-acting muscarinic antagonist (LAMA) to reduce exacerbation frequency, improve lung function, and enhance quality of life, as recommended by the most recent guidelines 1. The primary benefit of classifying patients as GOLD E is that it guides more aggressive therapy. These patients typically receive triple therapy in a single inhaler or as separate medications, such as fluticasone/vilanterol/umeclidinium (Trelegy Ellipta), budesonide/formoterol plus tiotropium, or similar combinations. Some key points to consider in the management of GOLD E COPD include:
- The use of triple therapy has been shown to improve lung function, symptoms, and health status, and reduce exacerbations compared to dual therapy or monotherapy 1.
- Additional options for patients who continue to have exacerbations despite triple therapy include roflumilast (a PDE-4 inhibitor), azithromycin (as anti-inflammatory prophylaxis), or consideration for lung volume reduction procedures in appropriate candidates.
- Pulmonary rehabilitation is also an important component of COPD management, and has been shown to improve symptoms, exercise tolerance, and quality of life, and reduce hospitalizations 1. The benefit of this classification is recognizing these high-risk patients early and implementing comprehensive therapy to break the cycle of frequent exacerbations, which otherwise leads to accelerated lung function decline and increased mortality. Key considerations in the management of GOLD E COPD include:
- Regular assessment of symptoms, lung function, and exacerbation history to guide therapy.
- Use of triple therapy as the foundation of treatment, with additional therapies added as needed.
- Consideration of pulmonary rehabilitation and other non-pharmacological interventions to improve symptoms and quality of life.
- Close monitoring for adverse effects of therapy, such as pneumonia with ICS use, and adjustment of therapy as needed.
From the Research
Benefits of GOLD E in COPD
The benefits of GOLD E in COPD can be understood by analyzing the treatment responses among different inhalation therapies for GOLD group E patients.
- Patients with COPD in GOLD group E should be further stratified to determine the appropriate initial inhalation therapy 2.
- The treatment with LABA + LAMA or LABA + LAMA + ICS had a lower incidence of exacerbations and frequent exacerbations compared with the patients treated with LAMA or LABA + ICS in the FEV1%pred <50% and CAT≥10 groups 2.
- Combination therapy with salmeterol/fluticasone and tiotropium leads to better control of symptoms and improved lung function, with no greater risk of side-effects, as compared to salmeterol/fluticasone or tiotropium alone in the treatment of COPD 3.
- The addition of FSC to TIO significantly improved lung function indices, including AM pre-dose FEV1, and reduced rescue albuterol use 4.
Treatment Options for GOLD E
Treatment options for GOLD E include:
- Long-acting muscarinic antagonist (LAMA)
- Long-acting β2-agonist (LABA) + inhaled corticosteroid (ICS)
- LABA + LAMA
- LABA + LAMA + ICS 2, 3, 4, 5
- Pulmonary rehabilitation is recommended for patients in groups B, C, and D 6.
Patient Stratification
Patient stratification is crucial in determining the appropriate treatment for GOLD group E patients.
- Patients can be stratified based on the COPD assessment test (CAT) scores and forced expiratory volume in one-second percentage of predicted (FEV1%pred) 2.
- The Global Initiative for Chronic Obstructive Lung Disease assigns patients with COPD into four groups based on the degree of airflow restriction, symptom score, and number of exacerbations in one year 6.