What are the latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines for managing Chronic Obstructive Pulmonary Disease (COPD)?

GOLD 2025 Guidelines for COPD Management

The latest GOLD guidelines prioritize a symptom-driven and exacerbation-based approach to COPD management, with long-acting bronchodilators as first-line therapy and treatment escalation based on clinical response rather than spirometry alone. 1

Diagnosis

COPD diagnosis requires post-bronchodilator spirometry showing FEV1/FVC <0.70, along with appropriate respiratory symptoms (dyspnea, chronic cough, sputum production, or wheezing) and significant exposure to noxious stimuli. 2

Key Diagnostic Updates:

• Pre-bronchodilator spirometry can now be used to rule out COPD, reducing clinical workload, while post-bronchodilator measurements confirm the diagnosis 1
• Repeat spirometry is recommended for patients with initial FEV1/FVC ratio between 0.6-0.8 to account for day-to-day variability and increase diagnostic specificity 2
• The fixed ratio of FEV1/FVC <0.70 remains the diagnostic threshold, though this continues to be controversial as it may overdiagnose COPD in patients over 60 years 2

Common pitfall: COPD is frequently both overdiagnosed and underdiagnosed due to lack of spirometry testing among symptomatic patients, resulting in inappropriate therapy and delayed diagnosis of other treatable conditions 2

Assessment and Classification

Treatment decisions are now based exclusively on symptoms and exacerbation history (Groups A-D), NOT on spirometric severity. 2, 1

ABCD Classification System:

• Group A: Low symptoms, low exacerbation risk
• Group B: High symptoms, low exacerbation risk (most common group at 28.3%) 3
• Group C: Low symptoms, high exacerbation risk (least common at 4.2%) 3
• Group D: High symptoms, high exacerbation risk (most common at 59.2%) 3

Symptom assessment tools: Use CAT (COPD Assessment Test) or mMRC (modified Medical Research Council) dyspnea scale 1, 3

Exacerbation risk: Based on ≥2 moderate exacerbations or ≥1 severe exacerbation (requiring hospitalization) in the past year 2

Pharmacological Treatment

Group A (Low Symptoms, Low Risk):

Short-acting bronchodilators (SABA or SAMA) as needed for mild intermittent symptoms 4

Group B (High Symptoms, Low Risk):

Start with long-acting bronchodilator monotherapy (LAMA or LABA), then escalate to LAMA+LABA dual therapy if symptoms persist 2, 1, 4

• The 2023 Canadian Thoracic Society and American Thoracic Society recommend starting with dual therapy (LAMA+LABA) upfront for patients with moderate-severe dyspnea or poor health status 2
• Single-inhaler dual therapy is preferred over multiple inhalers, as it reduces exacerbations and rescue medication use 2

Group C (Low Symptoms, High Risk):

LAMA or LAMA+LABA combination therapy 4

Group D (High Symptoms, High Risk):

Single-inhaler triple therapy (LAMA+LABA+ICS) is recommended upfront for patients with recurrent moderate or severe exacerbations 2

• Blood eosinophil count ≥300 cells/μL supports ICS use 2
• For eosinophils <100 cells/μL, consider adding oral therapies (azithromycin or N-acetylcysteine) to LAMA+LABA rather than escalating to triple therapy 2

Critical point on ICS withdrawal: Do NOT withdraw ICS in patients with moderate-high symptom burden and high exacerbation risk unless there are significant adverse effects, particularly if blood eosinophils ≥300 cells/μL 2

Treatment Escalation Algorithm:

1. Start with appropriate therapy based on ABCD group
2. Reassess at 3-6 months
3. If inadequate symptom control: escalate therapy
4. If excessive side effects or no benefit: consider de-escalation 2

Device selection considerations: Assess inhaler technique regularly, consider patient preference, cost, and environmental impact (dry powder inhalers have lower carbon footprint than MDIs) 2

Non-Pharmacological Management

Smoking Cessation:

Smoking cessation is the single most important intervention that influences COPD natural history, with long-term quit rates up to 25% when effective resources are dedicated 2

• Combination of pharmacotherapy (varenicline, bupropion, or nortriptyline) plus behavioral support increases cessation rates 2
• Nicotine replacement therapy increases long-term abstinence rates 2
• E-cigarettes' effectiveness as cessation aids remains uncertain 2, 1

Vaccinations:

Influenza vaccination reduces serious illness, death, and total exacerbations 2

Pneumococcal vaccination (PCV13 and PPSV23) is recommended for all patients ≥65 years 2

Pulmonary Rehabilitation:

Pulmonary rehabilitation improves symptoms, quality of life, and physical/emotional participation in everyday activities, and is recommended for all symptomatic patients, particularly Groups B, C, and D 2, 1, 4

Oxygen Therapy:

Long-term oxygen therapy improves survival in patients with severe resting chronic hypoxemia 2

• Do NOT routinely prescribe long-term oxygen for patients with stable COPD and resting or exercise-induced moderate desaturation, though individual factors should be considered 2

Advanced Interventions:

In select patients with severe emphysema refractory to optimized medical care, consider lung volume reduction surgery, bronchoscopic interventions (endobronchial valves or coils), or lung transplantation 2

Exacerbation Management

Exacerbations are classified as mild (treated with short-acting bronchodilators only), moderate (requiring antibiotics and/or oral corticosteroids), or severe (requiring hospitalization or emergency room visit) 2, 5

Acute Treatment:

Short-acting inhaled β2-agonists (with or without short-acting anticholinergics) are the initial bronchodilators for acute exacerbations 2, 5

• For moderate exacerbations: nebulized β2-agonist (terbutaline 5-10 mg) or anticholinergic (ipratropium 0.25-0.5 mg) 5
• For severe exacerbations or poor response: combine both agents 5
• Administer on arrival and at 4-6 hourly intervals (more frequently if needed) 5

Systemic corticosteroids (prednisolone 30 mg/day for 7-14 days) improve lung function, oxygenation, and shorten recovery time and hospitalization duration 2, 5

Antibiotics should be added when there is increased sputum purulence, volume, or dyspnea 2, 5

Non-invasive ventilation (NIV) should be the first mode of ventilation for acute respiratory failure 2, 1, 5

Important caveat: In hypercapnic respiratory failure, drive nebulizers with compressed air (not oxygen), providing supplemental oxygen via nasal prongs if needed 5

Post-Exacerbation:

Initiate or optimize maintenance therapy with long-acting bronchodilators before hospital discharge to prevent subsequent exacerbations 2

Comorbidity Management

Most patients with COPD die from comorbidities (lung cancer or heart disease) rather than COPD itself, making comorbidity management crucial 2

Cardiovascular Disease:

Selective β1-blockers are recommended for heart failure in COPD patients 1

Screen for peripheral arterial disease using ankle-brachial index, as prevalence is 5-fold higher in COPD patients 2, 1

Other Important Comorbidities:

• Untreated GERD is an independent risk factor for COPD exacerbations and should be treated 2, 1
• Screen for obstructive sleep apnea (OSA), as "overlap syndrome" worsens nocturnal hypoxemia and increases pulmonary hypertension risk 2
• Bronchiectasis is underdiagnosed in COPD and associated with longer exacerbations and increased mortality 2
• Risk for metabolic syndrome and diabetes is increased in COPD 2

Monitoring and Follow-up

Routine follow-up is essential to monitor symptoms, exacerbations, and objective measures of airflow limitation, adjusting therapy as disease progresses 2

• Evaluate and treat symptoms indicating worsening or development of comorbid conditions 2
• Assess inhaler technique regularly 2
• Review therapeutic regimen at each visit to determine when to modify management 2