This update to the GOLD guidelines includes new definitions of COPD and COPD exacerbation, emphasises combined bronchodilator therapy and minimises use of inhaled corticosteroids.

Sponsoring organisation: Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Background: The WHO and US National Institutes for Health convened the original GOLD expert panel in 1998 to make recommendations for managing chronic obstructive pulmonary disease (COPD). GOLD now has updated its last compre­hensive executive summary, published in 2017 (NEJM JW Gen Med Jun 15 2017 and Am J Respir Crit Care Med 2017; 195: 557­582).

Key points

• GOLD proposes a new, more inclusive definition of COPD that focuses on respiratory symptoms, anatomical area of abnormality (airways and alveoli) and airflow obstruction as demonstrated by forced vital capacity/forced expiratory volume in 1 second (FVC/FEV₁) below 0.7.
• A new definition of COPD exacerbation is also included; it focuses on dyspnoea or cough and sputum that worsen during 14 days or less, with associated inflammation due to airway infection, pollution or other insult to the airways. Severity is determined by dyspnoea intensity, respiratory rate, heart rate and oxygen saturation.
• Although cigarette smoking continues to be a predominant cause of COPD, more emphasis is placed on exposure to indoor biomass smoke and air pollution in low­- and middle­-income countries as a risk factor.
• A new recommendation is made for chest computed tomography if patients have persistent exacerbations, symp­toms out of proportion to airflow obstruction or evidence of air trapping/hyperinflation, to reveal alternate diagnoses or target specific therapies.
• Treatments are determined by (1) degree of airflow obstruction, (2) current symptoms, (3) history of moderate and severe exacerbations and (4) comorbidities.
• Previous treatment categories C and D have been combined into a new category, named E (for exacerbations). GOLD provides new guidance based on blood eosinophil level. Initial therapy for categories A, B, and E is as follows:
  – A: Long­-acting beta­-agonist (LABA) or long­-acting muscarinic antagonist (LAMA)
  – B: LABA + LAMA (change from monotherapy)
  – E: LABA + LAMA; if blood eosinophils are 0.30 × 10⁹ cells/L or higher, consider LABA + LAMA + inhaled corticosteroid (ICS). No recommendation is made (at any eosinophil level) for ICS without combined LABA + LAMA.
  – For patients with persistent exacerbations despite LABA + LAMA + ICS or for those who have more than 0.10 × 10⁹ cells/L, roflumilast (for patients with chronic bronchitis and FEV₁ below 50% of predicted) or azithromycin (in nonsmokers) can be considered.
• Pulmonary rehabilitation is recommended for patients in treatment groups B and E.
• Recommendations for oxygen therapy, ventilatory support and lung­-volume reduction surgery are unchanged in this update, although endobronchial valve and endoscopic lung­-volume reduction surgery are now included.
• Exacerbations should be treated with bronchodilators and prednisone (40 mg daily for five days). A five­- to seven-­day course of antibiotics is appropriate for patients with increased sputum volume and purulence or for patients on mechanical ventilation.

Comment: Six years after the last update, the 2023 GOLD report emphasises new definitions of both COPD and COPD exacerbation, with the former designed to be more inclusive and the latter to be more functional for clinicians. The most substantial changes to therapy are creating the ‘E’ category, more emphasis on LABA + LAMA combination treatment for most patients and minimising use of ICS. A 'pocket guide' to the 2023 guidelines is available online.

Patricia Kritek, MD, EdM, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.

Agustí A, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD executive summary. Am J Respir Crit Care Med 2023; 207: 819-837.

This summary is taken from the following Journal Watch titles: General Medicine, Ambulatory Medicine, Hospital Medicine.