News in COPD Treatment Recommendations in a Nutshell
We present an overview of the most important changes in the annually updated recommendations of the Global Initiative for Chronic Obstructive Lung Disease (GOLD).
Etiology of COPD
Chronic obstructive pulmonary disease (COPD) is a common, treatable disease characterized by respiratory symptoms and airflow obstruction. It is caused by changes in the airways or alveoli, usually due to long-term exposure to irritating gases or particles, most commonly tobacco smoke in developed countries.
COPD diagnosis should be considered in any patient with dyspnea, chronic cough or sputum production, frequent lower respiratory tract infections, and/or exposure to risk factors. Spirometry is essential for diagnosis.
Updates in COPD Diagnosis, Treatment, and Prevention Strategy
An international team of experts from the GOLD initiative conducts an extensive literature review each year to update its recommendations. Here are a few recent updates.
Inhaled Corticosteroids in COPD Treatment
Among the most significant changes in recent years is the clarification of the role of inhaled corticosteroids (ICS). Current recommendations since 2020 state that ICS therapy should be considered individually for each patient—it should be considered for patients with more than 2 moderate exacerbations per year or hospitalizations for exacerbation despite appropriate maintenance treatment with long-acting bronchodilator sympathomimetic (LABA), serum eosinophil level ≥ 300/μl, or asthma. On the other hand, recurrent pneumonia, a history of mycobacterial infections, and eosinophil levels < 100/μl argue against the initiation of ICS.
Recently, there has been a discussion about the potential impact of ICS on the development of lung malignancies. Studies with various designs have so far yielded entirely conflicting results, ranging from protective effects especially in ex-smokers, no impact on lung cancer incidence, to an increased risk of malignancies. Current recommendations state that there is no convincing evidence for either a positive or negative effect at this time, and results from studies with sufficient follow-up duration, optimal design, and patient population are awaited.
Triple Inhalation Therapy
The combination of LABA/ICS or LABA/long-acting anticholinergic (LAMA) provides a clear clinical benefit in terms of lung function, symptoms, and exacerbation risk compared to monotherapy. Fixed triple inhalation therapy LABA/LAMA/ICS offers further improvements in all these parameters compared to dual therapy. Recently, some clinical study results with triple combinations have started to suggest a reduction in mortality for symptomatic patients with frequent and/or severe exacerbations. However, this parameter was not the primary goal of the studies, and the results showed only a trend rather than a significant difference; therefore, it is necessary to wait for more evidence to confirm the impact of triple therapy on mortality.
Vitamin D Deficiency
Since 2020, GOLD recommendations suggest routinely testing every patient hospitalized for exacerbation of the disease for severe vitamin D deficiency (< 25 nmol/l). A recent meta-analysis has shown that supplementation in patients with low baseline vitamin D levels reduced the rate of exacerbations.
Caution with Electronic Cigarettes
Due to a lack of safety data, GOLD does not recommend using electronic cigarettes for smoking cessation. Cases of eosinophilic pneumonia, acute lung injury, diffuse alveolar hemorrhage, and respiratory bronchiolitis have been reported in association with their use. It has been shown that vitamin E acetate present in some e-cigarettes causes lung damage.
COVID-19
In light of the ongoing COVID-19 pandemic, a whole thematic section has been added to the recommendations. Among the key messages are the recommendations that patients should continue their oral and inhaled therapy as prescribed, even during the pandemic. During periods of high virus prevalence, spirometry is recommended only for patients requiring urgent diagnosis or assessment of lung function status before surgery. Vaccination against COVID-19 for COPD patients should follow national guidelines. The current report also includes recommendations for conducting remote consultations.
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Sources:
1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease (2022 report). GOLD, 2021 Nov 12. Available at: https://goldcopd.org/wp-content/uploads/2021/12/GOLD-REPORT-2022-v1.1-22Nov2021_WMV.pdf
2. Gupta N., Agrawal S., Chakrabarti S., Ish P. COPD 2020 guidelines—what is new and why? Adv Respir Med 2020; 88 (1): 38–40, doi: 10.5603/ARM.2020.0080.
3. Gupta N., Malhotra N., Ish P. GOLD 2021 guidelines for COPD—what's new and why. Adv Respir Med 2021; 89 (3): 344–346, doi: 10.5603/ARM.a2021.0015.
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