What does a "GOLD E" classification refer to in COPD (chronic obstructive pulmonary disease)?

GOLD E Classification in COPD

GOLD E is a high-risk classification introduced in the 2023 GOLD guidelines that identifies COPD patients based solely on exacerbation history—specifically those with ≥2 moderate exacerbations OR ≥1 severe exacerbation (requiring hospitalization) in the past year—regardless of symptom burden. 1, 2

What Changed and Why It Matters

The 2023 GOLD update fundamentally restructured COPD classification by merging the previous GOLD C and D groups into a single "E" category, eliminating symptom assessment (CAT/mMRC scores) from high-risk classification 2. This represents a major shift from the 2022 ABCD scheme, where:

• Old system: GOLD C = low symptoms + high exacerbation risk; GOLD D = high symptoms + high exacerbation risk
• New system: GOLD E = high exacerbation risk only (symptoms no longer factor into this classification)

The rationale was to simplify treatment decisions by focusing on the single most important predictor of future exacerbations and poor outcomes: past exacerbation history 1.

Defining Criteria for GOLD E

A patient qualifies as GOLD E with either:

• ≥2 moderate exacerbations in the past 12 months (requiring antibiotics and/or systemic corticosteroids)
• ≥1 severe exacerbation in the past 12 months (requiring hospitalization)

2

Important caveat: The 2026 GOLD update further expanded this to include patients with just 1 moderate exacerbation, which substantially increases the population classified as GOLD E 3. However, this change is controversial—evidence shows that a single moderate exacerbation has limited clinical impact at the population level, with future exacerbation risk typically remaining below 50% 3.

Clinical Characteristics of GOLD E Patients

Real-world data from 145,341 U.S. COPD patients revealed that 26.6% met GOLD E criteria 2. These patients demonstrate:

• Higher comorbidity burden, particularly cardiovascular conditions
• More frequent elevated blood eosinophil counts (≥300 cells/μL)
• Greater use of triple inhaler therapy (though still inadequate—only 14.2% of GOLD E patients with elevated eosinophils used triple therapy)
• Higher proportion of former smokers compared to non-GOLD E patients

2

The Controversy: Should C and D Have Been Combined?

Emerging evidence suggests the merger of GOLD C and D into GOLD E may be problematic 4. A study of 1,529 myCOPD app users found:

• CAT scores remained significantly different between original GOLD C and D patients after 12 months (P = 8.2 × 10⁻²³)
• Exacerbation rates differed significantly: Original GOLD C patients had lower exacerbation rates than GOLD D over the subsequent 12 months (P = 3.1 × 10⁻²)
• Paradoxically, GOLD B patients (high symptoms, low exacerbation risk) had higher CAT scores and exacerbation rates than GOLD C in follow-up

4

This suggests symptom burden remains clinically important for stratifying disease progression and future exacerbation risk, contradicting the rationale for eliminating it from the E classification.

Treatment Gaps in GOLD E

A critical finding: 34.8% of GOLD E patients had no evidence of any maintenance medication use 2. Among those who should receive triple therapy based on elevated eosinophils:

• Only 14.2% actually used triple inhalers
• Blood eosinophil testing remains underutilized—only 58.2% of GOLD E patients had documented BEC testing

2

This represents a massive treatment gap, as GOLD E patients are specifically those at highest risk who should be receiving intensive preventive therapy.

Practical Approach to GOLD E Classification

When encountering a patient with COPD:

1. Document exacerbation history over past 12 months:

   • Count moderate exacerbations (requiring antibiotics/oral steroids)
   • Count severe exacerbations (requiring hospitalization)

2. If ≥2 moderate OR ≥1 severe exacerbation → Classify as GOLD E

3. For patients with only 1 moderate exacerbation (per 2026 criteria):

   • Exercise caution before escalating to intensive therapy
   • Consider additional risk factors: age, symptom burden (CAT/mMRC), FEV₁, comorbidities
   • Individualize decisions—the evidence for aggressive treatment in this subgroup is weak 3

4. Still assess symptoms separately (CAT or mMRC) even though they don't define GOLD E—they remain important for:

   • Predicting future outcomes 4
   • Guiding bronchodilator intensity
   • Monitoring treatment response

5. Check blood eosinophil count in all GOLD E patients to guide ICS use

Key Pitfall to Avoid

Do not assume all GOLD E patients are identical. The original GOLD C patients (low symptoms, high exacerbation risk) behave differently from GOLD D patients (high symptoms, high exacerbation risk) over time 4. Consider maintaining awareness of symptom burden even within the E classification when making treatment decisions.