What are the GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines for COPD (Chronic Obstructive Pulmonary Disease) management in 2025 and what are the major changes?

GOLD Guidelines for COPD 2025: Major Changes and Recommendations

The GOLD 2025 guidelines introduce significant changes to COPD diagnosis and management, with the most notable being the recommendation to use pre-bronchodilator spirometry to rule out COPD and post-bronchodilator measurements to confirm the diagnosis, which will reduce clinical workload while ensuring accurate diagnosis. 1

Key Diagnostic Changes

• GOLD 2025 maintains that COPD diagnosis should be considered in individuals with chronic respiratory symptoms and/or exposure to risk factors, but introduces a new approach to spirometry 1
• Pre-bronchodilator spirometry is now recommended as an initial screening tool to rule out COPD, with post-bronchodilator measurements used to confirm the diagnosis 1
• This approach addresses the issue of "volume responders" who may have FEV1/FVC ≥0.7 pre-bronchodilator but <0.7 post-bronchodilator due to greater improvement in FVC relative to FEV1 1
• Post-bronchodilator results close to the threshold (FEV1/FVC <0.7) should be repeated to ensure diagnostic accuracy 1
• The fixed ratio of FEV1/FVC <0.7 remains the diagnostic threshold, despite ongoing controversy about this approach 1

Assessment and Classification

• COPD assessment continues to be based on symptoms and exacerbation history, moving away from relying primarily on spirometric values for treatment decisions 2
• The ABCD assessment tool has been modified, with some evidence suggesting that combining GOLD C and D groups may be reconsidered due to differences in symptom progression and exacerbation rates 3
• Symptom assessment using validated tools like COPD Assessment Test (CAT) or modified Medical Research Council (mMRC) dyspnea scale remains essential 2

Pharmacological Treatment Updates

• First-line treatment recommendations remain consistent with long-acting bronchodilators as the foundation of therapy 2:

  • Group A: A bronchodilator (short or long-acting)
  • Group B: Long-acting bronchodilator (LAMA or LABA)
  • Group C: LAMA as first choice
  • Group D: LAMA or LAMA+LABA combination

• Treatment escalation pathways have been clarified 1, 2:

  • For Group B patients with persistent symptoms: Escalate to LAMA+LABA combination
  • For Group C patients with exacerbations: Consider adding roflumilast if FEV1 <50% predicted and chronic bronchitis is present
  • For Group D patients with exacerbations: Consider triple therapy (LAMA+LABA+ICS)

• Single inhaler triple therapy is preferred over multiple inhalers requiring different techniques 2

Exacerbation Management

• Exacerbations continue to be classified as mild, moderate, or severe based on treatment requirements 4
• Short-acting inhaled β2-agonists remain the initial bronchodilators for acute exacerbations 4
• Systemic corticosteroids improve outcomes during exacerbations 4
• Antibiotics are recommended for exacerbations with increased sputum purulence and volume 4
• Non-invasive ventilation (NIV) is the first-line ventilation mode for acute respiratory failure 4

Non-Pharmacological Interventions

• Smoking cessation remains a cornerstone intervention that significantly impacts COPD progression 2

• Pulmonary rehabilitation is recommended for all symptomatic patients, particularly those with exercise limitations 2

• Oxygen therapy indications remain unchanged 2:

  • PaO2 ≤55 mmHg or SaO2 ≤88% with or without hypercapnia
  • PaO2 between 55-60 mmHg with evidence of pulmonary hypertension, peripheral edema, or polycythemia

• Annual influenza vaccination and pneumococcal vaccinations (PCV13 and PPSV23) are recommended for all COPD patients 2

Comorbidity Management

• Cardiovascular disease management remains important, with selective β1 blockers recommended for heart failure in COPD patients 1
• Screening for peripheral arterial disease using ankle-brachial index is recommended due to 5-fold higher prevalence in COPD patients 1
• "Overlap syndrome" (COPD + OSA) requires attention as it worsens night-time hypoxemia and increases risk for pulmonary hypertension 1
• Untreated GERD is recognized as an independent risk factor for COPD exacerbations 1
• Bronchiectasis is often underdiagnosed in COPD and associated with longer exacerbations and increased mortality 1

Advanced Interventions

• For selected patients with advanced emphysema refractory to optimized medical care, lung volume reduction (surgical or bronchoscopic) should be considered 2
• Lung transplantation remains an option for very severe COPD meeting specific criteria 2

Implementation Challenges

• Studies show variable adherence to GOLD guidelines in primary care, with over-treatment common in GOLD groups A and B 5
• Non-adherence to guidelines is most common in GOLD groups A (64%) and B (33%), primarily consisting of over-treatment 5
• Patients with high symptom load, frequent exacerbations, asthma overlap, and diabetes mellitus are more likely to receive guideline-concordant care 5

The GOLD 2025 guidelines continue to evolve toward a more personalized approach to COPD management while maintaining the core principles of symptom control and exacerbation prevention 6, 7.