What are the 2026 GOLD (Global Initiative for Chronic Obstructive Lung Disease) guideline updates for COPD (chronic obstructive pulmonary disease) management, including the phenotype‑driven approach, eosinophil count thresholds for inhaled corticosteroid use, and recommended pharmacologic regimens for groups A‑D?

GOLD 2026 COPD Management Updates

The GOLD 2026 guidelines have not been published yet; the most recent comprehensive COPD management recommendations come from the 2023 Canadian Thoracic Society guidelines and GOLD 2023 report, which emphasize blood eosinophil-guided triple therapy decisions, upfront dual bronchodilator therapy for symptomatic patients, and mortality reduction with single-inhaler triple therapy in high-risk populations. 1, 2

Key Classification Changes

The current GOLD classification system stratifies patients into groups A-D based exclusively on symptom burden (using CAT or mMRC scores) and exacerbation history, independent of spirometric severity. 1 However, recent guidelines have evolved beyond this framework:

• Group A (low symptoms, low exacerbation risk): Start with long-acting bronchodilator monotherapy (LAMA or LABA), with LAMA slightly preferred for superior exacerbation prevention. 2, 3

• Group B (high symptoms, low exacerbation risk): Initiate single-inhaler LAMA/LABA dual therapy directly rather than monotherapy, as this provides superior dyspnea relief and health status improvement. 1, 2, 3

• Group C (low symptoms, high exacerbation risk): Begin with LAMA monotherapy, then escalate to LAMA/LABA if exacerbations persist. 2

• Group D (high symptoms, high exacerbation risk): Single-inhaler triple therapy (LAMA/LABA/ICS) is strongly recommended upfront for patients with ≥2 moderate or ≥1 severe exacerbation in the past year, as it reduces all-cause mortality with risk ratios of 0.58-0.64 compared to dual therapy. 1, 2, 3

Blood Eosinophil Thresholds for ICS Decisions

Blood eosinophil counts now serve as critical biomarkers for ICS-containing regimen decisions:

• Eosinophils <100 cells/μL: Do not escalate from LABA/LAMA dual therapy to triple therapy. Instead, add oral therapies such as prophylactic azithromycin or N-acetylcysteine. 1, 2, 3 These patients derive minimal benefit from ICS and face increased pneumonia risk. 4

• Eosinophils 100-300 cells/μL: Triple therapy may be considered if patients have moderate-to-high symptom burden and ≥2 moderate or ≥1 severe exacerbation, though benefit is intermediate. 5, 4

• Eosinophils ≥300 cells/μL: Do not withdraw ICS in patients with moderate-high symptom burden and high exacerbation risk, as these patients derive the greatest benefit from ICS-containing regimens. 1, 2, 3 The rate ratio for exacerbation reduction is 0.57 (95% CI: 0.49-0.66) in this population. 4

Critical Eosinophil Measurement Considerations

Measure blood eosinophils OFF ICS treatment when possible, as ICS suppresses eosinophil counts and may underestimate true eosinophilic inflammation. 6 In patients where eosinophil count changes significantly during ICS treatment (≥200 cells/μL change), the off-ICS measurement and the magnitude of eosinophil suppression are more predictive of ICS response than the on-ICS measurement. 6

Recommended Pharmacologic Regimens by Group

Initial Therapy Algorithm

For newly diagnosed symptomatic COPD patients:

1. CAT <10, mMRC 1, FEV₁ ≥80%: Start LAMA or LABA monotherapy (LAMA slightly preferred). 2, 3

2. CAT ≥10, mMRC ≥2, FEV₁ <80%, no exacerbation history: Initiate single-inhaler LAMA/LABA dual therapy immediately. 1, 2, 3

3. CAT ≥10, mMRC ≥2, FEV₁ <80%, ≥2 moderate or ≥1 severe exacerbation: Start single-inhaler triple therapy (LAMA/LABA/ICS) upfront. 1, 2, 3 The number needed to treat for mortality benefit is 4, versus number needed to harm for pneumonia of 33. 3

Escalation Strategies

• From monotherapy: Escalate to LABA/LAMA dual therapy for persistent breathlessness. 2, 3

• From LABA/LAMA dual therapy: Add ICS (triple therapy) only if moderate-to-high symptom burden persists AND patient has ≥2 moderate or ≥1 severe exacerbation, particularly with eosinophils ≥300 cells/μL. 2

• For eosinophils <100 cells/μL on dual therapy with persistent exacerbations: Add roflumilast (if FEV₁ <50% and chronic bronchitis phenotype) or prophylactic macrolide (azithromycin in former smokers), rather than escalating to triple therapy. 1, 2, 3

De-escalation Considerations

Withdraw ICS if:

• Recurrent pneumonia develops (particularly in patients with eosinophils <100 cells/μL). 1, 2
• Significant ICS-related adverse effects occur (oral candidiasis, hoarse voice, skin bruising, diabetes, cataracts). 2

Do NOT withdraw ICS if:

• Eosinophils ≥300 cells/μL with moderate-high symptom burden and high exacerbation risk. 1, 2, 3
• Patient has concomitant asthma (asthma-COPD overlap). 2

Specific Medication Combinations

Preferred dual bronchodilator combinations:

• Indacaterol/glycopyrronium (once-daily, superior 24-hour bronchodilation). 2
• Olodaterol/tiotropium (once-daily, continuous 24-hour bronchodilation). 2

Triple therapy options:

• Beclomethasone/glycopyrrolate/formoterol (single-inhaler). 2
• Other single-inhaler triple combinations are preferred over multiple-device regimens to reduce medication errors and improve adherence. 1

Additional Pharmacologic Options

• Roflumilast (PDE4 inhibitor): Add for patients with chronic bronchitis phenotype, FEV₁ <50% predicted, and exacerbation history despite optimal inhaled therapy. Common adverse effects include diarrhea, nausea, weight loss, and headache. 2, 3

• Prophylactic macrolides: Consider azithromycin or erythromycin for former smokers with recurrent exacerbations despite triple therapy. Monitor for bacterial resistance and hearing impairment with azithromycin. 2, 3

• N-acetylcysteine or carbocysteine: Use in patients with low eosinophil counts (<100 cells/μL) who cannot be escalated to triple therapy. 2

Non-Pharmacologic Management

• Smoking cessation: The single most important intervention, with varenicline, bupropion, and nicotine replacement increasing long-term quit rates to 25%. 2

• Pulmonary rehabilitation: Strongly recommended for all symptomatic patients (Groups B, C, D), as it reduces readmissions and mortality when initiated within 4 weeks after exacerbation-related hospitalization. Do not initiate before hospital discharge, as this may compromise survival. 2, 3

• Long-term oxygen therapy (LTOT): Indicated for resting hypoxemia (PaO₂ ≤55 mmHg or SaO₂ ≤88%) confirmed on two occasions at least 3 weeks apart, or PaO₂ 55-60 mmHg with evidence of pulmonary hypertension, peripheral edema, or polycythemia. 2, 3

• Vaccinations: Annual influenza vaccine and pneumococcal vaccinations (PCV13 and PPSV23) for all patients ≥65 years. 2, 3

Common Pitfalls to Avoid

• Do not use ICS monotherapy in COPD—it increases pneumonia risk without exacerbation benefit. 2

• Do not prescribe ICS-containing regimens to low-risk patients without exacerbation history, as this exposes them to pneumonia risk without mortality benefit. 1, 2

• Do not delay triple therapy in high-risk exacerbators (≥2 moderate or ≥1 severe exacerbation)—starting with dual therapy and waiting for further exacerbations delays the mortality benefit. 2

• Do not use multiple inhaler devices with different inhalation techniques, as this increases exacerbations and medication errors. 1

• Do not rely on spirometry alone to guide treatment decisions—symptom burden (CAT, mMRC) and exacerbation history are equally important. 3

• Do not use oral glucocorticoids for chronic daily treatment—numerous side effects with no evidence of benefit. 2