What are the management recommendations for Chronic Obstructive Pulmonary Disease (COPD) according to GOLD (Global Initiative for Chronic Obstructive Lung Disease) 2025?

GOLD 2025 Management Recommendations for COPD

The GOLD 2025 guidelines recommend a comprehensive approach to COPD management that includes pharmacological and non-pharmacological interventions tailored to symptom burden and exacerbation risk, with long-acting bronchodilators forming the cornerstone of treatment for most patients. 1

Assessment and Classification

• COPD patients should be assessed using symptom burden (using CAT or mMRC scores) and exacerbation history to guide treatment decisions 1
• Spirometry is required for clinical diagnosis of COPD to confirm airflow limitation with a post-bronchodilator FEV1/FVC ratio <70% 2
• The GOLD classification divides patients into four groups (A-D) based on symptoms and exacerbation risk 1

Pharmacological Management

Initial Treatment by GOLD Group

• Group A (Low symptoms, Low risk): Short-acting bronchodilator (SABA or SAMA) as needed 1
• Group B (High symptoms, Low risk): Long-acting bronchodilator (LABA or LAMA) as first-line treatment 2, 1
• Group C (Low symptoms, High risk): LAMA as first-line treatment 2
• Group D (High symptoms, High risk): LAMA or LAMA+LABA combination as first-line treatment 1

Treatment Escalation

• For persistent symptoms in Group B: Escalate to LAMA+LABA combination 2
• For exacerbations in Group C: Consider adding roflumilast if FEV1 <50% predicted and patient has chronic bronchitis 2
• For exacerbations in Group D: Consider triple therapy (LAMA+LABA+ICS) 2
• Single inhaler triple therapy is preferred over multiple inhalers requiring different techniques 2

Management of Exacerbations

• Exacerbations are classified as mild (treated with short-acting bronchodilators only), moderate (requiring antibiotics and/or oral corticosteroids), or severe (requiring hospitalization) 2
• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, are recommended as initial bronchodilators for acute exacerbations 2
• Systemic corticosteroids improve lung function, oxygenation, and shorten recovery time during exacerbations 2
• Antibiotics are indicated for exacerbations with increased sputum purulence and volume 2
• Non-invasive ventilation (NIV) should be the first mode of ventilation for acute respiratory failure 2

Non-Pharmacological Interventions

Smoking Cessation

• Smoking cessation is a key intervention that influences the natural history of COPD 2
• Pharmacotherapy (varenicline, bupropion) and nicotine replacement therapy increase long-term quit rates 2

Pulmonary Rehabilitation

• Pulmonary rehabilitation is recommended for all symptomatic patients, especially those with exercise limitation 1
• Rehabilitation improves symptoms, quality of life, and physical and emotional participation in everyday activities 2

Oxygen Therapy

• Long-term oxygen therapy is indicated for patients with:
  • PaO2 ≤55 mmHg or SaO2 ≤88% with or without hypercapnia, or
  • PaO2 between 55-60 mmHg with evidence of pulmonary hypertension, peripheral edema, or polycythemia 2, 1

Vaccinations

• Annual influenza vaccination is recommended for all COPD patients 2, 1
• Pneumococcal vaccinations (PCV13 and PPSV23) are recommended for all patients over 65 years and younger patients with significant comorbidities 2

Advanced Interventions

• For selected patients with advanced emphysema refractory to optimized medical care, consider:
  • Lung volume reduction (surgical or bronchoscopic) for heterogeneous or homogeneous emphysema 2
  • Lung transplantation for very severe COPD meeting specific criteria 2

Follow-up and Monitoring

• Regular follow-up is essential to monitor symptoms, exacerbations, and airflow limitation 2
• Each follow-up visit should include discussion of the current therapeutic regimen 2
• Inhaler technique should be assessed regularly 2
• Environmental impact of inhaler devices should be considered when selecting treatment options 2

Special Considerations

• Consider macrolide therapy in former smokers with frequent exacerbations despite optimal inhaled therapy 2
• Patients with both COPD and obstructive sleep apnea should receive continuous positive airway pressure 2
• End-of-life and palliative care approaches should be discussed with patients with advanced disease 2