What are the updated Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria for treating Chronic Obstructive Pulmonary Disease (COPD)?

Updated GOLD Criteria for COPD

The updated GOLD criteria (2017-2018) fundamentally shifted COPD management by separating spirometric assessment from treatment decisions—treatment is now guided exclusively by symptoms and exacerbation history using the ABCD classification system, not by lung function severity. 1

Diagnostic Criteria

COPD diagnosis requires all three of the following elements 1:

• Post-bronchodilator FEV1/FVC ratio <0.70 confirming persistent airflow limitation
• Appropriate respiratory symptoms including dyspnea, chronic cough, sputum production, or wheezing
• Significant exposure to noxious stimuli (cigarette smoking or environmental/occupational exposures)

For patients with initial FEV1/FVC ratio between 0.6-0.8, repeat spirometry is recommended to account for day-to-day biologic variability and increase diagnostic specificity. 1

Spirometric Grading (Separate from Treatment Decisions)

While spirometry remains essential for diagnosis, the severity of airflow limitation is now assessed separately and no longer determines treatment intensity 1:

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

ABCD Assessment System for Treatment Decisions

The revolutionary change in GOLD 2017 is that ABCD groups are derived exclusively from patient symptoms and exacerbation history—spirometry no longer guides pharmacologic treatment intensity. 1

Symptom Assessment

Use either tool to categorize symptom burden 1, 2:

• mMRC dyspnea scale: ≥2 indicates high symptoms
• CAT score: ≥10 indicates high symptoms

Exacerbation Risk Assessment

Based on the previous year 1, 2:

• Low risk: 0-1 moderate exacerbations (not requiring hospitalization)
• High risk: ≥2 moderate exacerbations OR ≥1 severe exacerbation requiring hospitalization

ABCD Group Classification

• Group A: Low symptoms (mMRC 0-1 or CAT <10) AND low exacerbation risk
• Group B: High symptoms (mMRC ≥2 or CAT ≥10) AND low exacerbation risk
• Group C: Low symptoms AND high exacerbation risk
• Group D: High symptoms AND high exacerbation risk

Pharmacologic Treatment Algorithm

Group A (Low Symptoms, Low Risk)

Start with short-acting bronchodilator for intermittent symptoms or long-acting bronchodilator for persistent low-grade symptoms. 1, 2 Continue, stop, or switch based on response.

Group B (High Symptoms, Low Risk)

Begin with long-acting bronchodilator monotherapy (LAMA or LABA), escalating to dual bronchodilator therapy (LAMA + LABA) for persistent symptoms. 1, 2 Dual therapy is preferred over single agents for moderate-severe dyspnea. 2

Group C (Low Symptoms, High Risk)

LAMA is the preferred initial monotherapy. 1 For escalation with further exacerbations, LAMA + LABA combination is preferred over LABA + ICS due to concerns about pneumonia risk with ICS. 1

Group D (High Symptoms, High Risk)

Baseline therapy options include LAMA, LAMA + LABA, or LABA + ICS. 1

Escalation strategies for persistent symptoms or exacerbations: 1, 2

• Triple therapy (LAMA + LABA + ICS) for patients with blood eosinophils ≥300 cells/μL
• Add roflumilast if FEV1 <50% predicted with chronic bronchitis
• Add azithromycin (in former smokers ≥65 years on optimized therapy)

Blood eosinophil count ≥300 cells/μL supports ICS use; counts <100 cells/μL suggest minimal ICS benefit. 2

Non-Pharmacologic Management

Smoking cessation is the single most important intervention influencing COPD natural history, with long-term quit rates up to 25% when effective resources are dedicated. 2 Combination pharmacotherapy (varenicline, bupropion, or nortriptyline) plus behavioral support increases cessation rates. 2

Vaccinations are mandatory: 1

• Influenza vaccination annually for all COPD patients
• PCV13 and PPSV23 for patients ≥65 years
• PPSV23 for younger patients with significant comorbidities

Long-term oxygen therapy is indicated for: 1

• PaO2 ≤55 mmHg (7.3 kPa) or SaO2 ≤88%, confirmed twice over 3 weeks
• PaO2 55-60 mmHg (7.3-8.0 kPa) with pulmonary hypertension, peripheral edema, or polycythemia (hematocrit >55%)

Exacerbation Management

Exacerbations are classified as mild (short-acting bronchodilators only), moderate (bronchodilators plus antibiotics/oral corticosteroids), or severe (requiring hospitalization). 1

Acute treatment: 1, 2

• Short-acting β2-agonists ± short-acting anticholinergics as initial bronchodilators
• Systemic corticosteroids (prednisolone 30 mg/day for 7-14 days) improve lung function and shorten recovery
• Antibiotics when indicated (increased sputum purulence) reduce relapse and hospitalization duration
• NIV should be the first-line ventilation mode for acute respiratory failure

Initiate maintenance long-acting bronchodilators before hospital discharge. 1

Critical Pitfalls

The fixed FEV1/FVC ratio of 0.70 causes overdiagnosis of COPD in patients >60 years, though GOLD continues to recommend it for simplicity. 1 Consider lower limit of normal in older patients when clinical suspicion is low.

COPD is commonly both overdiagnosed and underdiagnosed due to lack of spirometry testing, resulting in inappropriate therapy and delayed diagnosis of other treatable conditions. 1

Most COPD patients die from comorbidities (lung cancer or heart disease) rather than COPD itself—comorbidity management is crucial for mortality reduction. 1, 2

Group C patients are rare in clinical practice (4.2% in one study), suggesting this classification may have limited clinical relevance. 3 Most patients fall into Group D (59.2%), indicating high symptom burden with frequent exacerbations drives real-world COPD severity. 3