The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has published a 2019 report on the global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Substantial changes have been made to recommendations for the initial and follow-up treatment of COPD. They now provide guidance on the role of blood eosinophil counts as a biomarker for patients who may or may not respond to inhaled corticosteroids.
GOLD recommend that initial treatment is based on symptoms and exacerbation risk in treatment-naive COPD, which are used to categorise patients into one of four GOLD Groups A, B, C or D, as per past guidelines.
A major change in this algorithm is for GOLD Group D patients (symptomatic: mMRC ≥2 / CAT ≥10), who should be offered either LAMA monotherapy, LABA/LAMA if highly symptomatic (CAT ≥20) or ICS/LABA if blood eosinophil count >300 cells/L (indicating likelihood of steroid responsive disease).
This report introduces a new algorithm on stepping up treatment in patients who remain symptomatic or continue to exacerbate despite initial treatment, as well as a guide to stepping down where there is a lack of clinical benefit or if side effects occur.
It is important to emphasise that these ‘follow-up’ treatment recommendations do not depend on GOLD group categories, as these apply only at the point of the initial diagnosis. The clarity of this algorithm will be useful for all healthcare professionals in managing COPD patients.
In December 2018 NICE published new COPD guidelines and it will be interesting to understand differences in recommendations that may arise between NICE and GOLD.