Advancing COPD Care: Insights from GOLD 2023 Report

Chronic Obstructive Pulmonary Disease (COPD), ranking as the third leading global cause of death with 3 million lives claimed in 2019, is poised to intensify in prevalence due to aging demographics and sustained exposure to risk factors. Despite its escalating burden, COPD faces inconsistent management practices, ranging from underdiagnosis and misdiagnosis to overtreatment, notably with systemic corticosteroids.

In response to this challenge, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) emerged in 1998, dedicated to heightening awareness and preventing and globally managing COPD. The GOLD report, inaugurated in 2001, is a beacon, furnishing evidence-based insights into COPD diagnosis, stable disease, exacerbation management, and comorbidity considerations. Embracing these recommendations can enhance patient outcomes and curtail COPD-related healthcare-resource utilization (HCRU).

The GOLD recommendations undergo an annual review to stay abreast of evolving knowledge, ensuring alignment with the latest breakthroughs, particularly in treatment and management. The most recent revision, the GOLD 2023 report, unveiled in November 2022, marks the fifth major update. This discussion delves into the pivotal alterations within the GOLD 2023 report, exploring their potential impact on clinical practices, notably in primary care settings.

Key Changes in the GOLD Report 2023

1. Definition and Taxonomy
   • New background information on COPD and new strategies for terminology and taxonomy have been incorporated (Chapter 1)
   • A new section on chronic bronchitis has been added (Chapter 1, page 13)
   • A new definition of COPD has been proposed: COPD is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction (Chapter 1, page 5)
   • A new definition of COPD exacerbation has been proposed, and a new set of parameters to assess exacerbation history has been included: an exacerbation of COPD is defined as an event characterized by dyspnea and/or cough and sputum that worsens in <14 days and is often associated with increased local and systemic inflammation caused by airway infection, pollution, or other insult to the lungs (Chapter 1, page 134)
2. Diagnosis
   • Additional information on screening and case finding has been included (Chapter 2, page 36)
   • New information on imaging and CT has been included (Chapter 2, page 43)
   • The ABCD grouping system has been updated to the ABE model to recognize the clinical relevance of exacerbations, independent of the level of symptoms (Chapter 2, page 40; Chapter 4, page 115)
3. Exacerbation management
   • ​​​​​​​​​​​​​​The topic of management of exacerbations has been expanded to include details of possible alternative causes of symptoms and a new table on diagnosis and assessment (Chapter 5, page 136)
4. Disease management: pharmacological therapies
   • ​​​​​​​​​​​​​​The information and figures outlining initial pharmacological treatment and follow-up pharmacological treatment have been updated; in particular, the positioning of LABA + LAMA and ICS + LABA have been updated (Chapter 4, page 115)
   • Further information on therapeutic interventions to reduce COPD mortality has been included (Chapter 3, page 67)
   • Issues related to inhaled delivery have been addressed (Chapter 3, page 69)
   • Information on the topic of adherence to inhaled COPD medications has been included (Chapter 3, page 71)
   • New information on the choice of inhaler device has been added (Chapter 4, page 112)
5. Disease management: non-pharmacological therapies
   • ​​​​​​​Vaccination recommendations for people with COPD have been updated in line with current guidance from the Centre for Disease Control and Prevention (Chapter 3, page 54)
   • A section on tele-rehabilitation has been added (Chapter 3, page 76)
   • The section on interventional and surgical therapies for COPD has been expanded (Chapter 3, page 82)
6. Comorbidities
   • ​​​​​​​​​​​​​​The sections on COPD and comorbidities and COVID-19 and COPD have been updated with the latest evidence (Chapter 6, page 154; Chapter 7, page 169)

 Table 1: Summary of New Classification of COPD Etiotypes

^{Figure 1: (A) Consolidated representation of the updated GOLD treatment algorithms, as interpreted by the authors. (B) Initial Pharmacological Treatment and Follow-up Pharmacological Treatment algorithms as presented in the GOLD. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease report 2023.}

Conclusion

The updates to the GOLD 2023 report provide a simplified approach to the management of COPD, which will support clinicians in addressing current gaps in patient care.

Further research and clarification are needed in several areas, including the identification of optimal treatments for patients with different etiotypes, the cutoffs of blood eosinophils to guide treatment decisions, and the use of triple therapy after COPD hospitalizations.

It will remain critical for clinicians to interpret how best to implement the latest GOLD recommendations in clinical practice, particularly within the primary care setting, to ensure patients receive optimal, personalized care. We call on clinicians to utilize these recommendations to assist in diagnosing patients with COPD earlier, identifying more exacerbations and stratifying their severity, and reducing mortality by selecting the appropriate life-saving interventions.

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Reference

1. Global Initiative for Chronic Obstructive Lung Disease. GLOBAL STRATEGY FOR PREVENTION, DIAGNOSIS AND MANAGEMENT OF COPD: 2023 Report [Internet]. Global Initiative for Chronic Obstructive Lung Disease – GOLD. 2023. Available from: https://goldcopd.org/2023-gold-report-2/