What are the Gold criteria 2025 for diagnosing and managing chronic obstructive pulmonary disease (COPD)?

GOLD Criteria 2025 for COPD Diagnosis and Management

The GOLD 2025 report recommends using pre-bronchodilator spirometry to rule out COPD and post-bronchodilator measurements to confirm the diagnosis, with a threshold of post-bronchodilator FEV1/FVC ratio <0.7 defining airflow obstruction. 1

Diagnostic Criteria

Initial Assessment

• COPD should be considered in individuals with chronic respiratory symptoms (progressive dyspnea, chronic cough, sputum production) and/or exposure to risk factors (tobacco smoke, biomass smoke, occupational exposures) 1
• A detailed medical history should include exposure to risk factors, pattern of symptom development, history of exacerbations, and impact of disease on patient's life 1

Spirometry Requirements

• Pre-bronchodilator spirometry is recommended as an initial test to investigate airflow obstruction 1
• If pre-BD spirometry shows FEV1/FVC ≥0.7, post-BD spirometry is not required except when clinical suspicion of COPD is high 1
• Post-BD spirometry with FEV1/FVC ratio <0.7 is required to confirm the diagnosis of COPD 1
• Post-BD results close to the threshold should be repeated to ensure correct diagnosis 1

Special Considerations

• Volume responders: Patients with significant gas trapping may have pre-BD FEV1/FVC ≥0.7 but post-BD FEV1/FVC <0.7 due to greater improvement in FVC relative to FEV1 1
• Flow responders: Patients with greater FEV1 improvement relative to FVC may increase FEV1/FVC from <0.7 pre-BD to ≥0.7 post-BD; these individuals require monitoring as they have increased likelihood of developing post-BD obstruction during follow-up 1
• Pre-BD FEV1 <80% predicted suggests higher probability of being a volume responder 1

Severity Classification

• GOLD 1 (Mild): FEV1 ≥80% predicted 2, 3
• GOLD 2 (Moderate): FEV1 50-79% predicted 4
• GOLD 3 (Severe): FEV1 30-49% predicted
• GOLD 4 (Very Severe): FEV1 <30% predicted

Treatment Approach

Initial Therapy

• Long-acting bronchodilator (either LAMA or LABA) is recommended as first-line therapy for symptomatic patients 2, 3, 4
• Short-acting bronchodilators should be prescribed as rescue medication for symptom relief 2, 3, 4
• Inhaled corticosteroids (ICS) are recommended for patients with more severe disease or frequent exacerbations 2, 3

Monitoring and Follow-up

• Follow-up should be scheduled in 4-6 weeks to assess response to therapy, inhaler technique, symptom control, and need for treatment adjustment 2, 3, 4
• Annual spirometry is recommended to monitor disease progression 2, 3, 4
• Further follow-up and investigations, including repeating spirometry after an interval, are recommended when clinical suspicion of COPD is high but diagnostic criteria are not met 1

Common Pitfalls and Caveats

• Using pre-BD values alone would lead to a significant increase (up to 36%) in the number of patients diagnosed with COPD, putting additional pressure on health services 1
• Spirometry quality is important; ideally, grade A results (at least three acceptable measurements within repeatability criteria) should be obtained 1
• Even grade E (only one acceptable test) or grade U (at least one usable but not acceptable measurement) readings can be used for diagnostic purposes when carefully considered alongside clinical information 1
• Bronchodilator responsiveness testing has poor discriminative properties for differentiating COPD from asthma 1
• CT scanning can provide information relevant to COPD diagnosis (e.g., presence of emphysema) but availability and cost currently preclude routine use 1
• Studies show significant variability in adherence to GOLD recommendations in primary care, with over-treatment common in GOLD groups A and B 5