New GOLD guidelines – How do we use them?

Abstract

The 2011 revision of the GOLD document (1, 2) has in some areas been changed substantially compared to previous versions. The new document strongly suggests that assessment of any COPD patient should involve the following 4 components: 1) assessment of symptoms, 2) assessment of airflow limitation, 3) assessment of exacerbation history, and 4) assessment of comorbidities. Instead of just evaluating stages as defined by FEV1, GOLD now suggests a combined assessment of symptoms and risk of exacerbations. Symptoms can be assessed by the mMRC breathlessness scale, the COPD Assessment Test (CAT) or the Clinical COPD Questinnaire (CCQ). Patients can be characterised as having few symptoms or many symptoms based on either of these questionnaires. Exacerbation risk can be assessed using exacerbation history and spirometry (FEV1), and patients are characterised as having either low risk or high risk of exacerbations. Patients with less than 2 exacerbations last year, no admissions because of exacerbations and an FEV1 of 50+ % of predicted have a low risk of exacerbations. Patients with 2+ exacerbations last year, one or more admissions or an FEV1 < 50 % of predicted have a high risk of exacerbations. This combined assessment can subsequently be used for determining treatment, both non-pharmacological and pharmacological treatment. The document emphasises the importance of smoking cessation and the strong evidence base for pulmonary rehabilitation and advocates physical exercise in all COPD patients. The document maintains that bronchodilators are the main drugs for COPD with inhaled corticosteroids and PDE4-inhibitors being reserved for patients at high risk of exacerbations only. The new GOLD document also includes new chapters on management of exacerbations and on managing COPD with comorbidities.