GOLD Guideline 2011:

Global Strategy for Diagnosis, Management, and Prevention of COPD

LULUK ADIPRATIKTO

The GOLD document

Chapter 1. Definition and overview

Chapter 2. Diagnosis & assessment

Chapter 3. Therapeutic options Chapter 4. Manage stable COPD Chapter 5. Manage exacerbations Chapter 6. COPD comorbidities

Definition of COPD
COPD: a common preventable and treatable disease, is characterized by persistent airflow limitation that is usually progressive and associated with an enhanced chronic inflammatory response in the airways and the lung to noxious particles or gases.

Exacerbations and comorbidities contribute to the overall severity in individual patients.

Source: GOLD guideline 2011 Update

Prevention of COPD
Primary and Secondary

A number of risk factors for COPD have been identified several of these enable primary prevention of COPD; e.g., smoking, indoor air pollution and poorly managed asthma. Smoking cessation is the single most important intervention in the smoking COPD patient As COPD is the result of cumulative harmful exposures, other exposures to dust, fumes and smoke should be reduced whenever possible
Source: GOLD guideline 2011 Update

Diagnosis of COPD
A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease. Spirometry is required to make the diagnosis in this clinical context; the presence of a postbronchodilator FEV1/FVC <0.70 confirms the presence of persistent airflow limitation and thus of COPD
Source: GOLD guideline 2011 Update

Assessment of COPD
1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess risk of exacerbations 4. Assess comorbidities

Source: GOLD guideline 2011 Update

Assessment of COPD
1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess riskthe of exacerbations Use COPD Assessment Test (CAT), 4. Assess comorbidities or the mMRC Breathlessness scale

Notes: The CAT score is preferred since it provides a more comprehensive assessment of the symptomatic impact of the disease.

Source: GOLD guideline 2011 Update

mMRC Dyspnoe scale (modified Medical Research Council)

Tingkat Tidak terganggu oleh sesak napas kecuali 1 saat olah-raga berat. Terganggu dengan sesak napas ketika Tingkat terburu-buru berjalan di tanah yang datar 2 atau mendaki tanjakan. Berjalan lebih lambat pada permukaan yang datar dibandingkan orang seusia Tingkat karena sesak napas atau harus berhenti untuk bernapas ketika berjalan pada 3 kecepatan sendiri di permukaan yang datar. Berhenti untuk bernapas setelah berjalan Tingkat 90 meter atau setelah beberapa menit di 4 permukaan yang datar Terlalu sesak untuk meninggalkan rumah Tingkat atau sesak saat berpakaian atau berganti 5 pakaian.

Assessment of COPD
1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess risk of exacerbations Use spirometry for grading severity according 4. to Assess comorbidities spirometry, using four grades split at 80%,

50% and 30% of predicted value

Source: GOLD guideline 2011 Update

Assessment of COPD
1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess risk of exacerbations 4. Assess comorbidities Use history of exacerbations & spirometry.

Two exacerbations or more within the last year or an FEV1 < 50% of predicted value are indicators of high risk

Source: GOLD guideline 2011 Update

Assessment of COPD
1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess risk of exacerbations 4. Assess comorbidities

Assess comorbidities and treat them appropriately. The most frequent comorbidities are CVD, depression and osteoporosis

Combined assessment of COPD

1. Assess symptoms 2. Assess degree of airflow limitation using spirometry 3. Assess risk of exacerbations

An opportunity to combine these assessments for the purpose of improving management of COPD

Combined assessment of COPD

4

RISK (GOLD Classification of Airflow Limitation)

(C)
3

(D)

2 or more

(A)
1
mMRC 0-1 CAT <10

(B)
0
mMRC 2+ CAT 10+

SYMPTOMS
(mMRC or CAT score)
Note: When assessing risk, choose the highest risk according to GOLD grade or exacerbation history

RISK (Exacerbation history)

(GOLD Classification of Airflow Limitation)

(C)
3 2

(D)

2 or more

(Exacerbation history)

(A)
1 mMRC 0-1 CAT <10

(B)
0 mMRC 2+ CAT 10+

Combined assessment of COPD

Exacerbation per year 1 1 2+ 2+ mMRC 0-1 2+ 0-1 2+ CAT < 10 10 < 10 10

RISK

SYMPTOMS
(mMRC or CAT score)

Patient A B C D

Characteristic Low risk, less symptoms Low risk, more symptoms High risk, less symptoms High risk, more symptoms

Spirometric classification GOLD 1-2 GOLD 1-2 GOLD 3-4 GOLD 3-4

RISK

Management of COPD
Pharmacological First choice
GOLD 4

Classification of Airflow Limitation

ICS + LABA or ICS + LAMA

GOLD 3

ICS + LABA or ICS + LAMA

2 or more

C
GOLD 2

Exacerbations per year

1

SABA or SAMA prn

GOLD 1

LABA or LAMA
0

A
mMRC 0-1 CAT <10 mMRC 2+ CAT 10+

Source: GOLD guideline 2011 Update

Previous Guideline: Therapy at each Stage of COPD

I: Mild
FEV1 80% pred

II: Moderate
FEV1 <80% 50% pred

III: Severe
FEV1 <50% 30% pred

IV: Very Severe

FEV1 <30% pred or FEV1 <50% pred + chronic respiratory failure

Active reduction of risk factor(s); influenza vaccination

Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add inhaled glucocorticosteroids if repeated exacerbations Add long-term oxygen if chronic respiratory failure. Consider surgical treatments

Treatment Progression

GOLD Report 2010

Management of COPD
Pharmacological First alternatives
GOLD 4

Classification of Airflow Limitation

LABA and LAMA

GOLD 3

ICS and LAMA ICS/LABA and LAMA ICS/LABA and PDE4-inh LAMA and LABA LAMA and PDE 4-inh

2 or more

C
GOLD 2

Exacerbations per year

1

LABA or LAMA or SABA and SAMA

LABA and LAMA

0

GOLD 1

A
mMRC 0-1 CAT <10 mMRC 2+ CAT 10+

Source: GOLD guideline 2011 Update

Management of COPD the aims

Relieve symptoms Improve exercise tolerance Improve health status Prevent disease progression Prevent and treat exacerbations Reduce mortality Reduce symptoms

Reduce risk

Source: GOLD guideline 2011 Update

Management of COPD
Pharmacological
Patient

First choice
SABA or SAMA prn

First alternatives
LABA or LAMA or SABA and SAMA
LABA and LAMA

Other alternatives
Theophylline
SABA and/or SAMA Theophylline PDE4-inh SABA and/or SAMA Theophylline

LABA or LAMA

ICS + LABA or LAMA

LABA and LAMA ICS & LAMA or ICS+LABA and LAMA or ICS+LABA & PDE4-inh or LABA and LAMA or LAMA and PDE4-inh

ICS + LABA or LAMA

Carbocysteine SABA and/or SAMA Theophylline

Source: GOLD guideline 2011 Update

Management of COPD
Non-pharmacological
Patient Essential Recommended Depending on local guidelines Flu vaccination Pneumococcal vaccination Flu vaccination Pneumococcal vaccination

Smoking cessation (can include pharmacological treatment) Smoking cessation (can include pharmacological treatment) Pulmonary rehabilitation

Physical activity

B-D

Physical activity

Source: GOLD guideline 2011 Update

Bronchodilators - Recommendations
For both 2-agonists and anticholinergics, long-acting formulations are preferred over short-acting formulations (Evidence A). The combined use of SABA or LABA and anticholinergics may be considered if symptoms are not improved with single agents (Evidence B). Based on efficacy and side effects inhaled bronchodilators are preferred over oral bronchodilators (Evidence A). Based on evidence of relatively low efficacy and more side effects, treatment with theophylline is not recommended unless other long-term treatment bronchodilators are unavailable or unaffordable (Evidence B).
Source: GOLD guideline 2011 Update

Steroid & PDE4 inhibitors - Recommendations

There is no evidence to recommend a short-term therapeutic trial with oral steroids in patients with COPD to identify those who will respond to ICS or other medications. Long-term treatment with ICS is recommended for patients with severe and very severe COPD and frequent exacerbations that are not adequately controlled by long-acting bronchodilators (Evidence A). Long-term monotherapy with oral corticosteroid is not recommended in COPD (Evidence A). Long-term monotherapy with ICS is not recommended in COPD because it is less effective than combination of ICS with LABA (Evidence A). The PDE4 inh may also be used to reduce exacerbations for patients with chronic bronchitis, severe and very severe COPD, and frequent exacerbations that are not adequately controlled by long-acting bronchodilators (Evidence B).

Source: GOLD guideline 2011 Update

COPD and co-morbidities

COPD patients are at increased risk for: Cardiovascular diseases a major comorbidity in COPD and probably
both the most frequent & most important disease coexisting with COPD

Osteoporosis

Osteoporosis & depression are also major comorbidities in COPD & are often under-diagnosed & associated with poor QoL & prognosis

Respiratory infections
Anxiety and Depression Diabetes Lung cancer
frequently seen in patients with COPD and has been found to be the most frequent cause of death in patients with mild COPD

These co-morbid conditions may influence mortality and hospitalizations and should be looked for routinely, and treated appropriately (as if the patient did not have COPD).

2011 GOLD revision Conclusions I

Spirometry is required to make the diagnosis of COPD in clinical context; the presence of a postbronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD. Prevention of COPD is to a large extent possible and should have high priority Assessment of COPD requires assessment of Symptoms, Degree of airflow limitation, Risk of exacerbation, and Comorbidities
Source: GOLD guideline 2011 Update

2011 GOLD revision Conclusions II

The combined assessment of symptoms and risk of exacerbations is the basis for management of COPD, both non-pharmacological and pharmacological

The beneficial effects of pulmonary rehabilitation as well as physical activity cannot be overstated
Comorbidities should be looked for and if present treated to the same extents as if the patient did not have COPD.
Source: GOLD guideline 2011 Update