The Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) Strategy Report has been one of the most important resources for clinicians working with COPD. In most years, the annual report covers all of the previous year’s major research articles. It also refines existing therapeutic recommendations for the prevention, diagnosis, and management of the condition. Periodically, the GOLD Science Committee does a stem-to-stern overhaul of their recommendations. In the past, some of these paradigm-shifting revisions have introduced concepts like assessing severity based on symptom burden and exacerbation frequency (rather than solely airflow obstruction) or the inclusion of the “treatable traits” philosophy of symptom management.1
The 2023 GOLD Report falls into the latter category, featuring a whopping 387 new references. Several of the major longitudinal COPD studies have published results over the last few years that could significantly change how we view and manage this complex syndrome. The new paradigm may also radically change how future research is designed, potentially leading to improved treatment pathways and even wholly new therapies. Let’s look at some of the changes that may have the most impact on the COPD world going forward.
New Definitions for a New Era
First and foremost, the definition of COPD itself has broadened. GOLD now describes it as a “heterogeneous lung condition characterized by chronic respiratory symptoms,” including frequent cough, sputum production, and activity limitation. While that may seem like a simple semantic change to previous versions, those iterations also generally focused on exposure to particles or other pollutants. In an interview earlier this year, pulmonologist and GOLD Science Committee member Dr. Antonio Anzueto mentioned that this was a very intentional choice.
“This disease is not just 78-year-old men,” he said, describing the new “face of COPD” as someone in their early 50s and more likely to be female.
Owing to this new understanding of COPD as less a single disease process and more a syndrome, a series of etiotypes has been proposed. Where phenotypes generally describe a set of symptoms or phenomena that appear together (for example, chronic bronchitis-type COPD), etiotypes focus on pathogenesis. This new focus is similar to some of the first theories of COPD, known as the “Dutch hypothesis” and including it as part of another syndrome called chronic, non-specific lung disease (NCSLD).2 Evidence was viewed to largely move away from this philosophy since it was first proposed in the mid-20th century, but more recent studies and expert reviews, including the recent Lancet Commission on COPD report3 have swung the pendulum once again.
The newly-proposed etiotypes include not only existing causes like cigarette smoking, biomass smoke exposure, and genetic factors (such as alpha-1 antitrypsin deficiency), but also things like COPD related to poor lung development early in life (including all the way back to the perinatal period). Infections and poorly-controlled asthma also get their own categories, and one category is set aside for COPD due to unknown origins. Defining these cohorts more specifically can improve the accuracy of future COPD research, as therapies deemed ineffective under the overall COPD umbrella may be found to work in specific groups.
In addition, a long-debated phenotype has been brought more into focus. Once known as “GOLD zero” stage, the preserved ratio impaired spirometry (PRISm) phenomenon has dogged clinicians and researchers for many years. People with PRISm have reductions in their FEV1 and FVC, but a normal FEV1/FVC ratio (without any signs of restrictive lung pathology). They also very often have the same types of symptoms and loss of exercise capacity as those with spirometric COPD. However, because they technically do not meet COPD diagnostic criteria, they are usually excluded from research studies, making evidence-based treatment difficult. However, new data from long-term international studies have revealed that as many as half of all those in the PRISm group go on to develop full-fledged chronic obstruction within five years, and when they do, it tends to be worse. That has tremendous implications for prioritizing earlier screening, diagnosis, and treatment to slow down the progression of COPD later on.
Another Revision to the “GOLD Box”
After recognizing that the idea of COPD severity was far more complex than simply measuring the degree of someone’s airflow obstruction, GOLD created the Combined Assessment tool, more commonly known as the GOLD Box. The box used symptom burden (as measured by the COPD Assessment Test or Modified Medical Research Council dyspnea score) and exacerbation history to assign one of four severity classes. These classes were then used to determine an initial therapy plan. That initial plan usually included an inhaled corticosteroid (ICS) for people with frequent exacerbations and high symptom burden. However, the ECLIPSE study suggests that exacerbation frequency is actually less predictive of ICS response than eosinophil levels. With more data suggesting that most COPD regimens should start with dual bronchodilators (and avoid ICS whenever possible), the two frequent exacerbation categories (C and D) have been combined into a single group, designated E to avoid confusion in future research. It should be noted, though, these severity classes continue to be seen as a starting point, with therapy management following the “treatable traits” pathways established in previous editions of the report.
Tweaks and Refinements
Areas of the report that did not get complete revamps did still see the customary annual refinements. Perhaps one of the most notable of these is in the section covering exacerbations. Based on the recent Rome Proposal consensus document,4 the definition of an acute exacerbation of COPD has been modified, and an evaluation tool has been developed to determine exacerbation severity. This is designed to help clinicians better understand patient needs during these episodes, as well as guide therapy decisions. Additional information about inhaler technique and selection was added to improve adherence. COVID-19 still looms over both stable and acute management of COPD, so initial evaluations of virtual pulmonary rehabilitation programs are included, with some discussion about how they may continue to benefit the COPD community even after the pandemic abates. And, of course, COVID-19 vaccines and boosters are still on the recommended vaccine list, as well as the new 20-valent pneumococcal vaccine.
All in all, the 2023 GOLD Strategy Report may be one of the most significant updates since the very first one. It should certainly move the conversation away from basic management long after symptoms begin to earlier diagnosis and more accurate treatment. Given that diagnostic delay has been a significant problem in COPD for many years, this should be very helpful to awareness and advocacy efforts. Research should also get a boost from the new sub-definitions of the various types of COPD, allowing for more effective and efficient therapies. The focus on education and rehabilitation once again demonstrates the critical role respiratory therapists play in taking care of those people living with COPD, both in and out of the hospital. It is remarkable to see all the progress made in this space, and all of us in the COPD world should be looking forward to what comes next!
- Rodriguez-Roisin, Md R. Word Count, 2334; references, 21 Twenty years of GOLD. Published online 1997:2000-2017.
- Sluiter HJ, Koeter GH, de Monchy JGR, Postma DS, de Vries K, Orie NGM. The Dutch Hypothesis (Chronic Non-Specific Lung Disease) Revisited. Vol 4.; 1991.
- Stolz D, Mkorombindo T, Schumann DM, et al. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. The Lancet. 2022;400(10356):921-972. doi:10.1016/S0140-6736(22)01273-9
- Celli BR, Fabbri LM, Aaron SD, et al. An updated definition and severity classification of chronic obstructive pulmonary disease exacerbations: The rome proposal. Am J Respir Crit Care Med. 2021;204(11):1251-1258. doi:10.1164/RCCM.202108-1819PP/SUPPL_FILE/DISCLOSURES.PDF
