What is the GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification for COPD (Chronic Obstructive Pulmonary Disease)?

GOLD Classification for COPD

The GOLD (Global Initiative for Chronic Obstructive Lung Disease) classification for COPD uses a combination of symptom assessment and exacerbation history to categorize patients into groups A, B, C, and D, which guides treatment decisions. 1

Diagnostic Criteria

• COPD diagnosis requires spirometry with a post-bronchodilator FEV1/FVC ratio <0.70 to confirm persistent airflow limitation 1
• Pre-bronchodilator spirometry can be used as an initial screening tool, with post-bronchodilator measurements confirming the diagnosis 2

GOLD Classification Components

1. Airflow Limitation Assessment

GOLD grades airflow limitation based on post-bronchodilator FEV1 as follows:

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

2. Symptom Assessment

Symptoms are assessed using validated questionnaires:

• mMRC (modified Medical Research Council) Dyspnea Scale:

  • Less symptoms: mMRC 0-1 1
  • More symptoms: mMRC ≥2 1

• CAT (COPD Assessment Test):

  • Less symptoms: CAT <10 1
  • More symptoms: CAT ≥10 1

• CCQ (Clinical COPD Questionnaire) (used in some countries):

  • Less symptoms: CCQ <1 1
  • More symptoms: CCQ ≥1 1

3. Exacerbation Risk Assessment

Exacerbation risk is determined by:

• Low risk: 0-1 exacerbations per year (not leading to hospitalization) 1
• High risk: ≥2 exacerbations per year OR ≥1 exacerbation leading to hospitalization 1

GOLD ABCD Assessment Tool

The 2017 GOLD update separated spirometric assessment from symptom and exacerbation risk assessment 1, 3:

• Group A: Low symptom burden (mMRC 0-1 or CAT <10) AND low exacerbation risk (0-1 exacerbations, no hospitalizations) 1
• Group B: High symptom burden (mMRC ≥2 or CAT ≥10) AND low exacerbation risk (0-1 exacerbations, no hospitalizations) 1
• Group C: Low symptom burden (mMRC 0-1 or CAT <10) AND high exacerbation risk (≥2 exacerbations or ≥1 hospitalization) 1
• Group D: High symptom burden (mMRC ≥2 or CAT ≥10) AND high exacerbation risk (≥2 exacerbations or ≥1 hospitalization) 1

Clinical Implications

• Treatment decisions are based primarily on symptoms and exacerbation history rather than spirometric values alone 1, 4
• Long-acting bronchodilators form the foundation of therapy across all groups 2
• Groups B and D typically have more severe airflow limitation than Groups A and C 4
• Despite being in the same GOLD group, patients may have different severities of airflow limitation 4

Important Considerations

• There is significant discordance between symptom assessment tools (mMRC vs. CAT), with studies showing that a CAT score of 17 rather than 10 may better correspond to mMRC ≥2 5
• Exacerbation risk assessment criteria (spirometry staging vs. exacerbation history) also show poor agreement (kappa 0.12) 5
• The BODE index (Body mass index, airflow Obstruction, Dyspnea, and Exercise capacity) may better discriminate for quality of life outcomes than GOLD classification alone 6
• Recent evidence suggests that airflow limitation severity may not be a good predictor of future exacerbations within the same GOLD group 4, 7

Comorbidity Management

• Comorbidities should be evaluated and appropriately managed in all COPD patients 1
• Cardiovascular disease, osteoporosis, diabetes, and GERD require special attention in COPD patients 1, 2
• Untreated GERD is an independent risk factor for COPD exacerbations 1, 2
• Bronchiectasis is often underdiagnosed in COPD patients and is associated with longer exacerbations and increased mortality 1