Global Initiative For Chronic Obstructive Lung Disease Guidelines Research Articles

Adequacy and prognostic impact of treatment for severe exacerbation of chronic obstructive pulmonary disease

ObjectiveTo define the clinical characteristics of patients hospitalised in pneumology and internal medicine departments for chronic obstructive pulmonary disease (COPD) exacerbation, to assess the compliance with the recommendations of the clinical practice guidelines and to determine the impact on the patients’ prognosis. MethodologyWe conducted a retrospective longitudinal study that randomly included patients hospitalised for COPD exacerbation in a tertiary hospital. We collected demographic and clinical variables (degree of dyspnoea and obstruction, previous exacerbations, comorbidities), readmission and mortality data and criteria for compliance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and the Spanish COPD guidelines (GesEPOC). We performed a univariate, multivariate and survival analysis. ResultsThe study included 108 patients, and the mean age was 71.48 ± 11.65 years. The readmission rate was 26.4% at 3 months and 43.4% at 1 year. The hospital mortality rate was 3.9%, the mortality rate at 3 months was 21.9%, and the mortality rate at 1 year was 27.4%. The patients hospitalised in the internal medicine department had higher mortality during hospitalisation (p = .043), at 3 months (p = .028) and at 1 year (p = .007) compared with the rates for the pneumology department. Overall compliance with the clinical guidelines was 63% for the clinical evaluation (less for the patients in internal medicine: 56.1% vs. 73.8%, p = .063). For the treatment, the compliance was 26.9% for GOLD and 28.7% for GesEPOC. Compliance with the GOLD guidelines in the use of corticosteroids was associated with a lower rate of long-term readmissions (p = .041) and hospital mortality (p = .007) and 3-month mortality (p = .05). ConclusionsThe clinical profile of the patients is currently similar to that previously reported, but their clinical progression was poorer. Overall compliance with the clinical guidelines for drug treatment was low, and only appropriate use of systemic steroids was associated with a reduction in early mortality and in medium-term readmissions.

Pulmonologists Adherence to the Chronic Obstructive Pulmonary Disease GOLD Guidelines: A Goal to Improve.

Background and objectives: Data about pulmonologist adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines showed a great variability and cannot be extrapolated. The present study investigates the current pharmacological prescribing practices in the treatment of chronic obstructive pulmonary disease (COPD) according to the 2017 GOLD guidelines, to determine the level of pulmonologist adherence and to identify possible factors that influence physician adherence. Materials and methods: This retrospective study took place between 1 February and 30 April 2018 in Pneumophtysiology Clinical Hospital Cluj-Napoca. We included 348 stable COPD outpatients classified according to the 2017 GOLD strategy in the ABCD risk groups. Pulmonologist adherence was defined as appropriate if the recommended pharmacological therapy was the first- or alternative-choice drug according to the guidelines, and inappropriate (overtreatment, undertreatment) if it was not in line with these recommendations. Results: The most prescribed treatment was the combination long-acting beta agonist (LABA) + long-acting antimuscarinic agent (LAMA) (34.77%), followed by LAMA + LABA + inhaled corticosteroid (ICS). Overall, pneumologist adherence was 79.02%. The most inappropriate therapies were in Group B (33.57%), followed by 33.33% in Group A. Compared to Groups C and D (analyzed together), Groups A and B had a 4.65 times higher chance (p = 0.0000001) of receiving an inappropriate therapy. Patients with cardiovascular comorbidities had a 1.89 times higher risk of receiving an inappropriate therapy (p = 0.021). ICS overprescription was the most common type of inappropriateness (17.81%). Groups C and D had a 3.12 times higher chance of being prescribed ICS compared to Groups A and B (p = 0.0000004). Conclusions: Pulmonologist adherence to the GOLD guidelines is not optimal and needs to be improved. Among the factors that influence the inappropriateness of COPD treatments, cardiovascular comorbidities and low-risk Groups A and B are important. ICS represent the most prescribed overtreatment. Further multicentric studies are needed to evaluate all factors that might influence the adherence rate.

Management of Chronic Obstructive Pulmonary Disease: Insights into Patient Profile – Use of Inhaled Corticosteroids/Long-Acting β2-Agonists or Long-Acting β2-Agonists/Long-acting Muscarinic Antagonists

The noncommunicable chronic obstructive pulmonary disease (COPD) ranks among the top five leading causes of death worldwide. It is a preventable chronic disease that has become a major public health concern globally, as well as in India. To improve the pharmacotherapeutic management of COPD and to increase awareness about the prevalence of the disease, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) has updated recommendations for the disease, based on the current clinical evidence. The present GOLD guideline endorses inhaled corticosteroids (ICS) combined with long-acting β2-agonists (LABA) for a subgroup of patients. The article is an attempt to clearly define patient profiles that stand to benefit from ICS/LABA, LABA/long-acting muscarinic antagonists (LAMA), and ICS/LABA/LAMA combination therapy based on current clinical evidence. The discussion is presented under the following headings: (i) disease burden worldwide, as well as in India; (ii) clinical symptoms and diagnosis of disease; (iii) risk factors leading to the development of disease; (iv) pharmacotherapeutic agents for COPD; (v) current updated recommendations from GOLD guidelines; (vi) subgroup of patients who can benefit from various combinations of therapeutic agents; and (vii) comparative analysis of clinical studies on various GOLD guideline-suggested combination therapies.

Recognizing asthma in patients with chronic obstructive pulmonary disease.

Newer guidelines for the use of inhaled corticosteroids in chronic obstructive pulmonary disease (COPD) state that they should be reserved for those patients who are likely to derive the greatest benefits from this medication class. This makes the latest Global Initiative for Chronic Obstructive Lung disease (GOLD) guidelines of great importance. This article examines the utility of a previous diagnosis of asthma, the presence of eosinophilia, elevated immunoglobulin E, and positive bronchodilator response in identifying the people with COPD who also have asthma, and it presents two case studies of patients with COPD to illustrate the use of the GOLD guidelines in clinical practice.

Adherence to Global Initiative for Chronic Obstructive Lung Disease guidelines in the real world: current understanding, barriers, and solutions.

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides a comprehensive review and guidance for clinicians managing patients with chronic obstructive pulmonary disease (COPD). However, adherence to GOLD guidelines has been suboptimal over the years. The current review summarizes the current body of literature addressing the multitude of reasons for the lack of adherence to GOLD guidelines in clinical practice. There continue to be several reasons for suboptimal adoption of GOLD guidelines in clinical practice. A primary and recurrent theme appears to be both delayed as well as missed diagnosis of COPD. There are several reasons for this including lack of awareness about current COPD guidelines, lack of availability as well as utilization of office spirometry and improper symptom assessment. Other issues include improper selection of proper pharmacotherapy options, misdiagnosis/mislabeling of COPD phenotypes, lack of smoking cessation counselling as well as enrollment in pulmonary rehabilitation. Potential solutions include adoption of clinical decision support systems, self-care models and careful phenotyping of COPD patients. There are currently several barriers for the adoption of GOLD guidelines into routine clinical practice. These barriers are all amenable to systematic solutions that will increase adherence to current GOLD guidelines.

Compliance of Pharmacotherapy with GOLD Guidelines: A Longitudinal Study in Patients with COPD.

ObjectiveTo evaluate the clinical implementation of pharmacotherapy recommendations for chronic obstructive pulmonary disease (COPD) based on the Global Initiative for chronic obstructive lung disease (GOLD) guidelines, in a longitudinal setting.MethodsThis is a sub-analysis of a prospective, non-interventional cohort study including patients with confirmed mild-to-very-severe COPD from seven pulmonary outpatient clinics in Switzerland. Follow-up visits took place annually for up to 7 years, from October 2010 until December 2016. For each visit, we evaluated the compliance of the prescribed pharmacotherapy with the concurrently valid GOLD guideline. We investigated whether step-ups or step-downs in GOLD stage or risk-group were accompanied by concordant changes in prescribed medication. Groups were compared via ANOVA.ResultsData of 305 patients (62±7 years, 66% men) were analysed. In 59.1% of visits, the prescribed medication conformed to the respective valid GOLD-guideline. Patients with very severe COPD were most likely to receive pharmacotherapy in compliance with guidelines. Step-ups and step-downs in risk group, requiring escalation, or de-escalation of pharmacotherapy, were noticed in 24 and 43 follow-up visits, respectively. Step-ups were adequately implemented in 4 (16.7%) and step-downs in six cases (14.0%).ConclusionThe compliance of COPD-pharmacotherapy with GOLD-guidelines is suboptimal, especially in lower risk groups. The high rates of missed out treatment-adjustments suggest that the familiarity of physicians with guidelines leaves room for improvement.

Clinical Guideline Highlights for the Hospitalist: The GOLD and NICE Guidelines for the Management of COPD

Chronic obstructive pulmonary disease in over 16s: Diagnosis and management1 RELEASE DATE: December 5, 2018 with update July 2019 PRIOR VERSION(S): NICE guideline CG101 June 2010, 2004 FUNDING SOURCE: Department of Health and Social Care, United Kingdom TARGET POPULATION: Patients age 16 and older with Chronic Obstructive Pulmonary Disease (COPD) GUIDELINE TITLE: Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2019 Report)2 RELEASE DATE: November 14, 2018 PRIOR VERSION(S): 2017, 2016, 2015, 2014, 2013, 2008, 2001 FUNDING SOURCE: The Global Initiative for Chronic Obstructive Lung Disease (GOLD) TARGET POPULATION: Adults with Chronic Obstructive Pulmonary Disease (COPD).

Pharmacological Management of Chronic Obstructive Pulmonary Disease by Low-Dose Theophylline: A Prospective Hospital-based Study in East Godavari of Andhra Pradesh

Background: High therapeutic dose of theophylline is not tolerated well by some patients. As it is an effective and affordable drug, the effectiveness of low-dose theophylline in pharmacological management of chronic obstructive pulmonary disease (COPD) was assessed. Aim: The aim of this study was to detect the efficacy of low-dose theophylline in COPD patients. Patients and Methods: Patients with stable COPD were enrolled. The complete blood picture (CBP), pulmonary function tests (PFTs), and St. George's Respiratory Questionnaire (SGRQ) were performed at enrolment. Patients were categorized into two groups: subjects and controls. All the participants were given medication for COPD as per the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. However, subjects were kept on low-dose sustained-release oral drug theophylline (150 mg twice daily) as an add-on. At every follow-up, once every 10 days up to 30 days, their parameters were recorded. The difference between the prognostic biomarkers was analyzed using the Student's “t”-test. Results: The CBP, SGRQ, and PFTs showed improvement in COPD patients treated with low-dose theophylline, i.e., subject group. Even though the PFTs improved in subjects, evidence of COPD remained. Low-dose theophylline may help to improve the quality of life in COPD patients. Conclusion: As a Cost-effective medication, low-dose theophylline can be used as an add-on drug to GOLD guidelines for the treatment of COPD. The subjects may feel better and can lead their normal life even with COPD.

Adecuación e impacto pronóstico del tratamiento de las exacerbaciones graves de la enfermedad pulmonar obstructiva crónica

ObjectiveTo define the clinical characteristics of patients hospitalised in pneumology and internal medicine departments for chronic obstructive pulmonary disease (COPD) exacerbation, to assess the compliance with the recommendations of the clinical practice guidelines and to determine the impact on the patients’ prognosis. MethodologyWe conducted a retrospective longitudinal study that randomly included patients hospitalised for COPD exacerbation in a tertiary hospital. We collected demographic and clinical variables (degree of dyspnoea and obstruction, previous exacerbations, comorbidities), readmission and mortality data and criteria for compliance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and the Spanish COPD guidelines (GesEPOC). We performed a univariate, multivariate and survival analysis. ResultsThe study included 108 patients, and the mean age was 71.48±11.65 years. The readmission rate was 26.4% at 3 months and 43.4% at 1 year. The hospital mortality rate was 3.9%, the mortality rate at 3 months was 21.9%, and the mortality rate at 1 year was 27.4%. The patients hospitalised in the internal medicine department had higher mortality during hospitalisation (p=.043), at 3 months (p=.028) and at 1 year (p=.007) compared with the rates for the pneumology department. Overall compliance with the clinical guidelines was 63% for the clinical evaluation (less for the patients in internal medicine: 56.1% vs. 73.8%, p=.063). For the treatment, the compliance was 26.9% for GOLD and 28.7% for GesEPOC. Compliance with the GOLD guidelines in the use of corticosteroids was associated with a lower rate of long-term readmissions (p=.041) and hospital mortality (p=.007) and 3-month mortality (p=.05). ConclusionsThe clinical profile of the patients is currently similar to that previously reported, but their clinical progression was poorer. Overall compliance with the clinical guidelines for drug treatment was low, and only appropriate use of systemic steroids was associated with a reduction in early mortality and in medium-term readmissions.

The Impact of Interprofessional Monitoring and Education on the Usage of Systemic Glucocorticoids in Acute Exacerbations of Chronic Obstructive Pulmonary Disease: A Retrospective, Medication Use Review.

BackgroundSystemic corticosteroid therapy for chronic obstructive pulmonary disease (COPD) exacerbations is routine in clinical practice, however, dosing is variable. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) panel recommends a short course of systemic corticosteroids for acute COPD exacerbation treatment. Despite these recommendations, institutions continue to use higher doses and longer durations of systemic corticosteroid therapies.MethodsThis single-center, retrospective, cohort study evaluated systemic corticosteroid use in inpatient treatment of COPD exacerbations. Data were collected on patients with a diagnosis of COPD exacerbation from October 2017 to February 2018 in both the control and education groups. An interprofessional, learner-centric, quality improvement, educational seminar was performed. Providers were given accompanying pocket reference material for improved adherence to GOLD guidelines for the management of acute COPD exacerbations.ResultsOf the 137 charts reviewed in the control group, 130 of 137 patients (94.9%) received systemic corticosteroid doses exceeding GOLD guideline recommendations. These patients received an average daily dose of 147.5 mg of prednisone equivalents. These patients also experienced more adverse drug reactions as compared to their post-intervention counterparts. The 105 charts examined post-educational intervention revealed 47 of 105 patients (44.8%) received GOLD guideline-directed doses of systemic corticosteroids. This was an improvement from 2.9% (4 of 137) in the control group (p-value < 0.001). The average daily dose decreased to 58 mg daily (p-value < 0.001), and the number of doses over the recommended 40 mg of prednisone equivalents (54 of 105) was a 43.5% reduction (p-value < 0.001). Length of stay also decreased in the education group from 6.1 +/- 4.1 to 4.7 +/- 2.8 days (p-value 0.009). The 30-day readmission rate, however, was not statistically different between the two groups, 31.4% pre- and 21.0% post-educational intervention (p-value 0.098).ConclusionsThe interprofessional education seminar and pocket reference sheet realigned clinical practice with guideline-based therapy in this tertiary care, community hospital. These data validate that learner-centric innovation will benefit patient outcomes and improve the educational potential of the interdisciplinary rounding team.

Management of COPD in Anhui Province: compliance with GOLD guidelines

Abstract Background COPD is a major public health concern of global scope, especially in China. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines are international and national recommendations to manage COPD. Little is known about level of adherence of COPD management among exacerbated COPD inpatients to GOLD guidelines in China. The current study aimed to compare COPD management (vaccination and treatment of COPD exacerbation) among hospitalized patients in Anhui Province with GOLD guidelines and identify risk factors influencing vaccination coverage and guideline-compliant care. Methods A retrospective clinical audit of medical records was conducted in a hospital in Anhui Province in China, involving 1132 patients hospitalized with exacerbated COPD within 2016-2017. Descriptive analysis was conducted to evaluate compliance to GOLD recommendations (version 2017). Logistic regression was conducted to detect the association between guideline-consistent care and variables. Results Extreme deficiency in the vaccination coverage (0%) was found. Regarding pharmacological management, some adherence to prescribing short-acting bronchodilators timely (43.5%) and prescribing long-acting bronchodilators (55.0%) was observed; nonetheless, only 26.1% of patients received systemic corticosteroids or antibiotics for the recommended duration (&amp;lt;7 days) and only 17.0% did not receive methylxanthines. Age, education level, occupational status and disease severity were independently associated with guideline-consistent treatment. Conclusions The implementation of GOLD recommendations in Anhui Province was unsatisfactory. Interventions to increase the vaccination coverage among COPD patients and to optimize the treatment of COPD exacerbation are imperative, requiring efforts at the hospital and policy levels. Key messages This is the first clinical audit study investigating the COPD management among hospitalized COPD patients in China. The implementation of GOLD recommendations in Anhui Province was unsatisfactory.

CRP testing may help guide antibiotic use for COPD exacerbations

C-reactive protein (CRP)-guided prescribing of antibiotics in patients with an acute exacerbation of COPD resulted in fewer patients receiving antibiotics during the initial consultation and over the first 4 weeks of follow-up compared with those receiving usual care, according to results of the PACE study published in the New England Journal of Medicine.1Butler CC et al.N Engl J Med. 2019; 281: 111-120Crossref Scopus (91) Google Scholar In addition, the two groups had similar clinical outcomes. The cause of acute exacerbations of COPD may vary, with some triggered by bacterial respiratory infections and others by viruses. Unfortunately, it is difficult to determine which patients may benefit from antibiotics (i.e., those with bacterial infections) and which do not need them. Therefore, having a reliable biomarker that can be assessed in the clinic would be beneficial in reducing unnecessary antibiotic use in these patients. The PACE study was a multicenter trial in which 653 patients with an acute exacerbation of COPD (mean age 68.1 y, 51.6% male) were randomized to point-of-care CRP testing to help guide antibiotic prescribing (n = 325) or to usual care (n = 324).1Butler CC et al.N Engl J Med. 2019; 281: 111-120Crossref Scopus (91) Google Scholar The patients were enrolled from 86 general medical practices in the United Kingdom from January 2015 to February 2017. In the CRP-guided group, the guidance stated that for patients with a CRP level lower than 20 mg/L, antibiotics are unlikely to be beneficial and usually should not be prescribed. For those with a CRP level from 20 mg/L to 40 mg/L, antibiotics may be beneficial, mainly if purulent sputum is present; and for those with a CRP level higher than 40 mg/L, antibiotics are likely to be beneficial. Fewer patients in the CRP-guided group reported receiving antibiotics compared with those receiving usual care (57% vs. 77.4%), with comparable clinical outcomes between the two groups, according to the clinical COPD questionnaire given at 2 weeks. Overall, fewer patients in the CRP-guided group received antibiotics at the initial consultation (47.7% vs. 69.7%) or over the first 4 weeks of follow-up (59.1% vs. 79.7%). The 2019 GOLD (Global Initiative for Chronic Obstructive Lung Disease) guidelines comment on the use of CRP to help guide antibiotic prescribing during COPD exacerbations.2https://goldcopd.org/wp-content/up-loads/2018/11/GOLD-2019-v1.7-FINAL-14Nov2018-WMS.pdfGoogle Scholar The organization noted that study data on this biomarker have been contradictory, and CRP is elevated in both bacterial and viral infections, making it difficult to determine if antibiotics should be used. Therefore, GOLD stated that CRP should not be used to guide antibiotic use in patients with COPD exacerbations. Instead, GOLD highlighted data on use of procalcitonin, suggesting that this biomarker is more specific for bacterial infections and may be of greater value to help determine if antibiotics should be given to those with COPD exacerbations. Several studies have suggested that procalcitonin-guided antibiotic treatment reduced antibiotic exposure and adverse effects without affecting clinical outcomes. However, the majority of data is of low to moderate quality, and additional well-designed studies are needed to confirm the utility of this biomarker. GOLD recommends that antibiotics be given to patients with COPD exacerbations who meet any of these criteria: Patient has the three cardinal symptoms (increase in dyspnea, sputum volume, and sputum purulence); patient has two of the cardinal symptoms if increased sputum purulence is one of them; or patient requires mechanical ventilation. Antibiotics are recommended to be given for 5 to 7 days, and the choice of therapy should be based on local bacterial resistance patterns. The organization noted that appropriately used antibiotics for COPD exacerbations can help shorten recovery time and reduce the risk of early relapse and hospitalization duration. In an accompanying editorial on the findings of the PACE study, the authors wrote, “In our view, the findings from this study are compelling enough to support CRP testing as an adjunctive measure to guide antibiotic use in patients with acute exacerbations of COPD. Whether primary care practices in the United States would embrace point-of-care CRP testing is another matter, given the regulatory requirements for in-office laboratory testing and uncertainty about reimbursement.”3Brett AS et al.N Engl J Med. 2019; 281: 174-175Crossref Scopus (6) Google Scholar The PACE results need to be considered along with the GOLD guidelines. For now, symptomatic patients with COPD exacerbations should be treated appropriately until further studies can confirm the utility of CRP or procalcitonin.

Comparison of safety pattern of drugs used in chronic obstructive pulmonary disease patients in a tertiary care hospital

Background: As per GOLD (Global initiative for chronic obstructive lung disease) guidelines bronchodilators are required for symptomatic treatment of chronic obstructive pulmonary disease (COPD) patients. Currently there is no evidence to say about the safety of fixed dose combinations used in COPD patients. Since the drugs are to be taken for longer period, it is essential to know the safety aspects of these drugs. Moreover we don’t have adequate studies and documentation to say that a particular drug combination is better and safer for COPD patients.Methods: Prospective, open labelled, randomized, comparative, interventional clinical study conducted by the Departments of Pharmacology and Pulmonary Medicine of Basaveshwara Medical College and Hospital, Chitradurga in 40 COPD patients.Results: The fixed dose combinations of drugs used in both the treatment groups i.e. salmeterol/fluticasone and tiotropium/formoterol were equally safer and well tolerated. Some side effects noticed during the course of treatment were statistically significant when compared between the 2 groups, however they were milder and predictable adverse drug reactions.Conclusions: Systemic and severe adverse drug reactions were not observed during 8 week treatment period and the local side effects observed were mild in both the treatment groups. Hence the fixed dose combinations of salmeterol or fluticasone and tiotropium or formoterol are found to be safer for maintenance therapy in COPD patients.

Costs of pharmacotherapy of chronic obstructive pulmonary disease in relation to changing Global Initiative for Chronic Obstructive Lung Disease guidelines (2007, 2011, and 2017 updates).

INTRODUCTION Chronic obstructive pulmonary disease (COPD) is one of the most common chronic noninfectious diseases. The clinical management is determined by patient assignment to the severity stage of the disease in accordance with the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. OBJECTIVES Our aim was to determine the economic implications of changing GOLD guidelines (2007, 2011, and 2017 updates) and their impact on the direct costs of pharmacological treatment of patients diagnosed with COPD. PATIENTS AND METHODS This analysis was based on data provided by a group of 298 out of 500 randomly selected primary care physicians in Poland (response rate, 59.6%). Each primary care physician provided information on 10 consecutive patients with COPD. These data were used to simulate the economic consequences of the 2007, 2011, and 2017 GOLD guideline updates. RESULTS Regardless of the GOLD guidelines used, pharmacotherapy of patients with a very severe form of COPD was most expensive. Pharmacotherapy costs would be reduced with each subsequent guideline. In the same group of 2597 COPD patients, the average monthly cost of the first‑line pharmacotherapy as well as the overall costs of pharmacotherapy (first- and second‑line) per patient would be the lowest when applying the therapeutic regimen in accordance with the 2017 GOLD guidelines. CONCLUSIONS Implementation of 2011 and 2017 GOLD guidelines, as compared with the 2007 update, would result in a reduction of direct costs of COPD treatment.

Hospital Care of Older Patients With COPD: Adherence to International Guidelines for Use of Inhaled Bronchodilators and Corticosteroids

ObjectivesWe aimed to analyze the prevalence and impact of COPD in older patients hospitalized in internal medicine or geriatric wards, and to investigate adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, associated clinical factors, and outcomes. DesignData were obtained from REgistro POliterapie SIMI (REPOSI), a prospective multicenter observational registry that enrolls inpatients aged ≥65 years. Setting and ParticipantsOlder hospitalized patients enrolled from 2008 to 2016 with a diagnosis of COPD. MeasuresWe evaluated adherence to the 2018 GOLD guidelines at admission and discharge, by examining the prescription of inhaled bronchodilators and corticosteroids in COPD patients. We also evaluated the occurrence of outcomes and its association with COPD and guideline adherence. ResultsAt hospital admission, COPD was diagnosed in 1302 (21.5%) of 6046 registered patients. COPD patients were older, with more impaired clinical and functional status and multiple comorbidities. Overall, 34.3% of COPD patients at admission and 35.6% at discharge were adherent to the GOLD guidelines. Polypharmacy (≥5 drugs) at admission [odds ratio (OR): 3.28, 95% confidence interval (CI): 2.24-4.81], a history of acute COPD exacerbation (OR: 2.65, 95% CI: 1.44-4.88) at admission, smoking habit (OR: 1.45, 95% CI: 1.08-1.94), and polypharmacy at discharge (OR: 6.76, 95% CI: 4.15-11.0) were associated with adherence to guidelines. COPD was independently associated with the risk of cardiovascular and respiratory death and rehospitalization occurrence compared to patients without COPD during follow-up. Adherence to guidelines was inversely associated with the occurrence of death from all causes (OR: 0.12, 95% CI: 0.02-0.90). Conclusions/ImplicationsCOPD was common in older patients acutely hospitalized, showing an impaired functional and clinical status. Prescriptions for older COPD patients were often not adherent to GOLD guidelines. Poor adherence to guidelines was associated with a worse clinical status. There is a need to improve adherence to guidelines in treating COPD patients, with the ultimate goal of reducing clinical events.

Adherence to the GOLD Guideline in COPD Management of South Korea: Findings from KOCOSS Study 2011-2018.

The guidelines for chronic obstructive pulmonary disease (COPD) treatment are important for the management of the disease. However, studies regarding the treatment adherence to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines have been scarce in Korea. Therefore, to examine the adherence to the GOLD guidelines, we examined the patterns of prescribed medication in COPD patients from 2011 to 2018. Patients were classified as having been appropriately and inappropriately treated (overtreatment or undertreatment) for the GOLD group. Appropriate medical therapy was defined as using the first choice or alternative choice drug recommended in the GOLD guidelines. Inappropriate therapy was classified as overtreatment or undertreatment in accordance with the categorization in the GOLD guidelines. According to treatment of 2011 GOLD guidelines, there was inappropriate treatment in 52.3% in group A, 47.3% in group B, 56.3% in group C, and 17.8% in group D. According to treatment of 2017 GOLD guidelines, there was inappropriate treatment in 66.7% in group A, 45.3% in group B, 14.3% in group C, and 24.0% in group D. The common type of inappropriate COPD treatment is overtreatment, with inhaled corticosteroid (ICS) containing regimens. In conclusions, adherence to the GOLD guideline by the pulmonologist in clinical practice is still low in Korea. Therefore, we need better strategies to both optimize the use of the guidelines and adhere to the guidelines as well.

Outpatient Management of Chronic Obstructive Pulmonary Disease: Physician Adherence to the 2017 Global Initiative for Chronic Obstructive Lung Disease Guidelines and its Effect on Patient Outcomes.

BackgroundChronic obstructive pulmonary disease (COPD) is a common and preventable illness that carries significant economic and social burden. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) provides a comprehensive review of the available literature for the diagnosis and management of COPD. Despite being considered the standard of care, adherence to the GOLD guidelines varies among practitioners. In addition, there is yet to be a clear correlation between misalignment with GOLD practicing guidelines and patient outcomes. We studied the outpatient management of COPD, with special attention paid to whether or not adherence to the 2017 GOLD guidelines affected patient outcomes.MethodsThis retrospective electronic medical record review study observed the outpatient management of patients with COPD, aged 18 year or older, who presented to the suburban primary care office. Patients who received treatment according to the GOLD guidelines were compared with the patients who did not. Categorical data were analyzed as frequencies with percentages. Frequencies were compared using Chi-square and Fisher’s exact tests. A P value < 0.05 was used to determine statistical significance.ResultsA total of 158 patients were included in this study. Thirty-six percent of the patients were treated according to the GOLD guidelines. There was no significant difference in the mortality, exacerbations or hospitalizations between the patients who were treated according to the GOLD guidelines and those who were not. Comparing prescribing practices for those treated according to the GOLD guidelines versus those who were not, a significant difference in management occurred in regards to long acting beta agonist (P < 0.05) and inhaled corticosteroid therapy (P < 0.001). The differences in the use of other pharmacological and nonpharmacological agents were not significant.ConclusionsAdherence to the 2017 GOLD guidelines had no statistically significant difference in patient outcomes. GOLD nonadherent patients received long-acting beta agonist and inhaled corticosteroid therapy at a significantly higher frequency compared to GOLD-adherent patients.

Impact of changing GOLD guidelines (2007-2011-2017) on assignment of a COPD patient to disease severity category.

IntroductionThe international standard for the recognition and treatment of chronic obstructive pulmonary disease (COPD) is guided by a regularly updated set of criteria developed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD).AimTo investigate the impact of updated COPD management guidelines from 2007 to 2017 (GOLD 2007, GOLD 2011 and GOLD 2017) on the assignment of patients into individual therapeutic groups, examining both individual and population dimensions.Material and methodsEach of 500 randomly chosen primary care physicians in Poland provided information on 10 individual COPD patients (disease history, clinical status, treatment and pharmacotherapy). This data was used to simulate the consequences of the implementation of the GOLD 2007, 2011 and 2017 guidelines.ResultsA group of 298 physicians of 500 approached provided information on 2597 patients (64.2% males) aged 29–96 (61.6 ±11.1 years). Based on GOLD 2007 guidelines, most patients (56.7%) presented a severe stage of COPD. GOLD 2011 updates would significantly increase the proportion of patients with the most severe stage of disease, and this group would be predominantly classified as moderate or severe in GOLD 2007. The implementation of GOLD 2017 guidelines would result in a significant migration of patients towards the lightest (category A) form of the disease.ConclusionsUpdates to the GOLD 2007 COPD guidelines for GOLD 2011 and 2017 would have a significant impact on the classification of patients for particular therapeutic groups. As a result of the migration of patients to particular therapeutic groups, the pharmacological treatment would also change.

Chronic Obstructive Pulmonary Disease in Older Adults: Part II: Considerations for Inhaler Selection.

Inhaler administration for patients with chronic obstructive pulmonary disease (COPD) can be challenging, as it requires correct recall and execution of multiple steps. Older adults may have a higher risk of incorrectly administering inhalers versus the general population due to age-related visual, cognitive, and functional impairments. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 report states that in addition to advanced age, use of multiple inhalers and lack of previous inhaler education can negatively impact technique. Improper inhaler use can lead to poor disease control, increased acute care utilization, and reduced quality of life. Therefore, regular evaluation of technique is emphasized by the GOLD guidelines to improve patient outcomes. Health care professionals on geriatric interdisciplinary teams can work together to achieve proper technique and evaluate for age-related limitations that may guide the choice of inhalers in older adults with COPD. [Journal of Gerontological Nursing, 44(10), 10-15.].

Systemic Corticosteroid and Antibiotic Use in Hospitalized Patients With Chronic Obstructive Pulmonary Disease Exacerbation.

Effective inpatient chronic obstructive pulmonary disease (COPD) exacerbation management is critical to appropriately manage health care resources. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines provide recommendations on appropriate systemic corticosteroid and antibiotic use, in select patients, for COPD exacerbation. To determine the impact of GOLD guideline-recommended systemic corticosteroid and antibiotic therapy in the hospital setting on clinical outcomes in patients with COPD exacerbation. This was a noninterventional, retrospective, single-center study. Adults admitted to a non-intensive care unit internal medicine service with documented COPD exacerbation were included. Two analyses were conducted evaluating systemic corticosteroid and antibiotic therapy. A total of 220 patients were included in the systemic corticosteroid cohort. No difference in 30-day readmission rates was demonstrated for the standard (⩽200 mg prednisone equivalents [PEs] for exacerbation course) and high-dose groups (>200 mg PEs; 20.5% vs 13.1%, respectively; P = 0.15). Hospital length of stay (LOS) was significantly shorter for patients prescribed standard-dose therapy (3 days [2-4.5] vs 4 days [2-6]; P < 0.001). A total of 174 patients were included in the antibiotic cohort. For the appropriate and inappropriate antibiotic use groups, no significant differences were observed between 30-day readmission rates (15% vs 18.4%, respectively; P = 0.57) and hospital LOS (4 days [2-5] in both groups; P = 0.97). Conclusion and Relevance: Hospital LOS was shorter for patients prescribed standard-dose systemic corticosteroids; however, no differences in other clinical outcomes were found in either cohort. Use of guideline-recommended systemic corticosteroid and antibiotic therapy is recommended for hospitalized patients with COPD exacerbation.