What are the initial and long-term management strategies for Chronic Obstructive Pulmonary Disease (COPD) according to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) report?

Initial and Long-term Management of COPD According to GOLD 2025

The management of COPD should follow a stepwise approach based on patient classification into Groups A, B, C, or D, with initial pharmacotherapy determined by symptom burden and exacerbation risk, and long-term management involving both pharmacological and non-pharmacological interventions to reduce disease progression and improve quality of life. 1

Initial Assessment and Classification

• COPD patients should be classified into groups A, B, C, or D based on symptom burden and exacerbation history 1
• Group A: low symptoms, low exacerbation risk
• Group B: high symptoms, low exacerbation risk
• Group C: low symptoms, high exacerbation risk
• Group D: high symptoms, high exacerbation risk 1

Initial Pharmacological Management

Group A

• Start with short-acting bronchodilator (SABA or SAMA) as needed for symptom relief 2
• Can be either short-acting or long-acting bronchodilator depending on patient preference 2
• Continue bronchodilator if symptomatic benefit is observed 2

Group B

• Initial therapy should be a long-acting bronchodilator (LABA or LAMA) 2
• Long-acting bronchodilators are superior to short-acting bronchodilators taken intermittently 2
• For persistent breathlessness on monotherapy, use of two bronchodilators (LABA/LAMA) is recommended 2
• For severe breathlessness, initial therapy with two bronchodilators may be considered 2

Group C

• Start with a LAMA as it is preferred for exacerbation prevention compared to LABAs 2
• If exacerbations persist, consider adding a second long-acting bronchodilator (LABA/LAMA) or using LABA/ICS 2

Group D

• Initial therapy should be LABA/LAMA combination 2
• LABA/LAMA combinations show superior results compared with single bronchodilator therapy 2
• LABA/LAMA combination is superior to LABA/ICS combination in preventing exacerbations 2
• LABA/ICS may be first choice for patients with history of asthma-COPD overlap or high blood eosinophil counts 2

Long-term Pharmacological Management

Escalation Strategy

• For patients who develop additional exacerbations on LABA/LAMA therapy, consider:
  • Escalation to LABA/LAMA/ICS triple therapy 2
  • Switch to LABA/ICS; if ineffective, add LAMA 2

For Persistent Exacerbations Despite Triple Therapy

• Consider adding roflumilast for patients with FEV1 <50% predicted and chronic bronchitis 2
• Consider adding a macrolide in former smokers (monitor for resistant organisms) 2
• Consider stopping ICS if pneumonia risk is high 2

Key Pharmacological Recommendations

• Long-term monotherapy with ICS is not recommended 2
• Long-term oral corticosteroids are not recommended 2
• Statin therapy is not recommended for prevention of exacerbations 2
• Antioxidant mucolytics are recommended only in selected patients 2

Non-Pharmacological Management

Risk Reduction

• Smoking cessation should be continually encouraged for all current smokers 2
• Reduce exposure to occupational dusts, fumes, gases, and indoor/outdoor air pollutants 2

Education and Rehabilitation

• Provide personalized self-management education 2
• Pulmonary rehabilitation programs for patients with high symptom burden (Groups B, C, D) 2
• Exercise training should combine constant load or interval training with strength training 1

Nutritional Support

• Nutritional supplementation for malnourished patients 2

Vaccinations

• Influenza vaccination for all COPD patients 2
• Pneumococcal vaccinations (PCV13 and PPSV23) for patients >65 years and younger patients with significant comorbidities 2

Oxygen Therapy

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

Ventilatory Support

• Non-invasive ventilation (NIV) may be considered for selected patients with pronounced daytime hypercapnia and recent hospitalization 2
• Continuous positive airway pressure for patients with both COPD and obstructive sleep apnea 2

Interventional and Surgical Options

For Advanced Disease

• Lung volume reduction (surgical or bronchoscopic) for selected patients with heterogeneous or homogeneous emphysema and significant hyperinflation 2
• Bullectomy for selected patients with large bullae 2
• Lung transplantation for selected patients with very severe COPD 2

Exacerbation Management

• Short-acting inhaled β2-agonists, with or without short-acting anticholinergics, as initial bronchodilators 2
• Systemic corticosteroids (40mg prednisone daily for 5 days) to improve lung function and shorten recovery time 2
• Antibiotics when indicated (increased sputum purulence with dyspnea or increased sputum volume) 2
• Maintenance therapy with long-acting bronchodilators should be initiated before hospital discharge 2
• NIV as first-line ventilation for acute respiratory failure 2

Monitoring and Follow-up

• Regular monitoring of symptoms, exacerbations, and lung function 2
• Adjust therapy as disease progresses 2
• Evaluate and treat worsening symptoms or development of comorbidities 2

Common Pitfalls and Caveats

• ICS use increases risk of pneumonia, especially in current smokers, older patients, those with prior exacerbations/pneumonia, low BMI, or severe airflow limitation 1
• Despite guideline recommendations, real-world data show frequent overuse of ICS in patients who may not benefit 3
• Methylxanthines are not recommended due to increased side effect profiles 2
• Antitussives cannot be recommended for COPD 2
• Drugs approved for primary pulmonary hypertension are not recommended for pulmonary hypertension secondary to COPD 2