Updated guidelines for chronic obstructive pulmonary disease (COPD) highlight changes in diagnosis, strategies for deescalation of therapy, options for nonpharmacologic therapies, and an emphasis on the importance of comorbidities for the management of patients with COPD.
The Global Strategy for the Diagnosis, Management, and Prevention of COPD (GOLD) 2017 Report, published online January 27 in the American Journal of Respiratory and Critical Care Medicine and on the GOLD website, arose from a collaboration of 22 COPD experts who reviewed published research through October 2016.
As before, the guidelines recommend evaluation for COPD in individuals with a history of risk factors or with dyspnea, chronic cough, or sputum production, using a postbronchodilator FEV1/FVC < 0.70 cutoff for diagnosis. In addition to family history, risk factors from childhood include low birthweight and childhood respiratory infections. Other risk factors include exposure to tobacco smoke, home cooking or heating fuels smoke, and occupational dusts, vapors, fumes, gases, and other chemicals.
One of the key changes in the revision is the separation of symptom evaluation from spirometric assessment. Although spirometry remains necessary to make the diagnosis, assessment goals should focus on symptoms, risk for exacerbations, and determining the effect of the disease on the patient's overall health. That assessment can then be used to place individual patients in the A, B, C, and D groups that guide therapy.
"The major change was peeling off spirometry and making spirometry a diagnostic and obstruction severity marker, but removing it from pharmacologic considerations in principle, with one exception," said report coauthor Fernando Martinez, MD, chief of the Division of Pulmonary and Critical Care Medicine at Weill Cornell Medical Center/NewYork-Presbyterian Hospital in New York City.
"Spirometry remains a key diagnostic feature and an important modality in defining severity of airflow obstruction," Dr Martinez told Medscape Medical News. "Therapeutically, it has limited relevance for pharmacotherapeutic options except for roflumilast."
Yet spirometric thresholds remain important for other treatments. "It does have relevance for nonpharmacologic therapies, including lung volume reduction and lung transplantation," Dr Martinez added.
He also noted that the new recommendations include a slight change in the definition of exacerbation, which is simplified and more practical in clinical use, along with a better evidence-based description of its optimal management and prevention.
Another addition to the new GOLD report is an in-depth discussion of escalation and deescalation treatment strategies, whereas past reports primarily focused only on initial therapy recommendations.
"We have extensively revised the pharmacotherapeutic recommendations to include step-up and step-down therapeutic algorithms," Dr Martinez told Medscape Medical News. "We have also modified the therapeutic considerations and have removed the first line in alternative therapies. What we now provide is additional rationale for initial recommended pharmacotherapies and possible alternative options for each of the patient categories (ABCD)."
The guidelines also include greater emphasis on use of combined bronchodilators as first-line therapies.
The updated GOLD report further adds a thorough review of nonpharmacologic treatment options, in addition to receiving influenza and pneumococcal vaccinations to decrease the risk for lower respiratory tract infections. The most important aspect of any treatment plan remains smoking cessation, and pulmonary rehabilitation remains highly beneficial.
"Pulmonary rehabilitation is a comprehensive intervention based on thorough patient assessment followed by patient-tailored therapies (e.g., exercise training, education, self-management interventions aimed at behavior changes to improve physical and psychological condition and promote adherence to health-enhancing behaviors in patients with COPD)," write lead author Claus F. Vogelmeier, MD, professor of medicine and head of the Department for Pulmonary Medicine at the University of Marburg, Germany, and colleagues. "Pulmonary rehabilitation can reduce readmissions and mortality in patients following a recent exacerbation." However, the authors note that initiation of pulmonary rehabilitation before hospital discharge may increase risk for death.
Oxygen therapy can increase the survival of patients with severe resting hypoxemia, although long-term oxygen therapy in those with stable COPD with moderate or exertional hypoxemia does not lengthen lifetimes or reduce the risk for hospitalization. Evidence on the benefits of ventilatory support remain unclear, although patients with obstructive sleep apnea should use continuous positive airway pressure to improve survival and reduce hospitalization risk.
Comorbidity Management Is Key
"There remains strong emphasis on the understanding of diagnosing and managing comorbid conditions in the COPD patient," Dr Martinez said, referring to the expanded discussion on comorbidities in the report. In addition to treating obstructive sleep apnea, the GOLD report notes the importance of awareness and management of cardiovascular disease, osteoporosis, anxiety and depression, and gastroesophageal reflux.
Evidence-supported surgical options, to be considered in selected patients when indicated, include lung volume reduction surgery, bullectomy, lung transplant, and some bronchoscope interventions. Such options are discussed in greater detail in the revised report than in previous ones.
"There's also a later emphasis and description on the role of palliative care and comprehensive disease management," Dr Martinez told Medscape Medical News. Discussion of end-of-life and hospice care are discussed, as well as symptom control and palliative care to address dyspnea, pain, anxiety, depression, fatigue, and poor nutrition.
According to Dr Martinez, the GOLD statement is annually updated as needed, but undergoes a major revision every few years as more evidence emerges and requires consideration in clinical practice changes.
"This is the next due major revision, and we took the opportunity based on the feedback that we had received after the last major revision to make modifications that simplified the recommendations and added additional evidence base to make the therapeutic schema more practical and easy to apply in a broad range of clinical settings," he said.
Dr Martinez reports grants from National Institutes of Health, personal fees from Continuing Education, Forest Laboratories, Janssen, GlaxoSmithKline, Nycomed/Takeda, AstraZeneca, Boehringer Ingelheim, Bellerophon (formerly Ikaria), Genentech, Novartis, Pearl, Roche, Sunovion, Theravance, CME Incite, Annenberg Center for Health Sciences at Eisenhower, Integritas, InThought, National Association for Continuing Education, Paradigm Medical Communications LLC, PeerVoice, UpToDate, Haymarket Communications, Western Society of Allergy and Immunology, Proterixbio (formerly Bioscale), Unity Biotechnology, ConCert Pharmaceuticals, Lucid, Methodist Hospital, Columbia University, Prime Healthcare Ltd, WebMD, PeerView Network, California Society of Allergy and Immunology, Chiesi, and the Puerto Rico Thoracic Society.
Am J Respir Crit Care Med. Published online January 27, 2017. Abstract
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Cite this: COPD Guidelines Update Treatment, Management Options - Medscape - Feb 02, 2017.