GOLD Criteria and Treatment for COPD
GOLD Classification System
The GOLD 2018 document uses a two-dimensional ABCD assessment schema that classifies patients based on symptom burden and exacerbation risk, NOT on spirometric severity alone. 1
Spirometric Staging (1-4)
- Stage 1 (Mild): FEV₁ ≥80% predicted 1
- Stage 2 (Moderate): FEV₁ 50-79% predicted 1
- Stage 3 (Severe): FEV₁ 30-49% predicted 1
- Stage 4 (Very Severe): FEV₁ <30% predicted 1
ABCD Assessment Groups
The current GOLD classification separates patients into four groups (A, B, C, D) based on:
- Symptom burden: Assessed using validated questionnaires 1
- Exacerbation history: Number of exacerbations in the previous year 1
Critical caveat: The 2017 and 2018 GOLD versions deliberately do NOT use spirometric stage to determine ABCD group assignment, representing a major shift from earlier versions. 1
Pharmacologic Treatment Algorithm
Group A (Low Symptoms, Low Risk)
- Initial therapy: Short-acting bronchodilator for intermittent symptoms 1
- For persistent low-grade symptoms: Long-acting bronchodilator (LAMA or LABA) 1
- Reassessment: Stop or switch medication classes based on response 1
Group B (High Symptoms, Low Risk)
- First-line: Long-acting bronchodilator monotherapy (LAMA or LABA) 1
- For persistent symptoms: Escalate to dual bronchodilator therapy (LAMA + LABA) 1
- Important consideration: If major discrepancy exists between symptom severity and spirometric impairment, reassess for asthma or asthma-COPD overlap and consider LABA/ICS combination 1
Group C (Low Symptoms, High Risk)
- Preferred initial therapy: LAMA 1
- If further exacerbations occur: Escalate to LAMA + LABA 1
- Alternative pathway: LABA + ICS may be considered 1
Group D (High Symptoms, High Risk)
- Initial therapy: LAMA + LABA combination 1
- For persistent symptoms or further exacerbations: Add ICS to LAMA + LABA (triple therapy) 1
- Additional options for frequent exacerbators:
Non-Pharmacologic Management
Risk Factor Reduction
Smoking cessation is the single most cost-effective intervention and must be addressed at every visit. 1
- Document tobacco use status at every encounter 1
- Implement evidence-based cessation strategies for every tobacco user 1
- Address indoor and outdoor air pollution exposure 1
Vaccination
The GOLD document recommends influenza and pneumococcal vaccination for all COPD patients, though the 2018 version curiously provides limited supporting data compared to CDC recommendations. 1
Device Selection and Education
- Critical requirement: Assess patient's ability to use specific inhaler devices, considering orthopedic limitations and inspiratory muscle weakness 1
- Mandatory practice: Educate, train, and reassess proper inhaler technique at every visit 1
Key Treatment Principles
Individualized Approach
Treatment selection must account for: 1
- Patient's clinical profile and symptom burden
- Exacerbation history
- Drug availability and cost
- Patient preference and ability to use delivery device
Monitoring Strategy
- Frequency: Reassess every 12 weeks during initial treatment phase 1
- Assessment tools: Symptom questionnaires, exacerbation frequency, spirometry 1
Common Pitfalls to Avoid
Do not use spirometric stage alone to guide pharmacotherapy - The ABCD classification is symptom and exacerbation-based, not FEV₁-based 1
Do not assume proper inhaler technique - Many patients use devices incorrectly; reassessment at every visit is essential 1
Do not overlook ICS-associated pneumonia risk - While recent larger studies suggest lower exacerbation rates with LABA/ICS versus LABA/LAMA, pneumonia risk remains a consideration 1
Do not delay smoking cessation interventions - This remains the most impactful intervention regardless of disease severity 1