GOLD Guidelines for COPD Care: Evolving Strategies for Exacerbation Prevention

Announcer:
You’re listening to Clinician’s Roundtable on ReachMD. On this episode, Mr. Brian Bizik will discuss the recent guideline updates from the Global Initiative for Chronic Obstructive Lung Disease, or GOLD. Mr. Bizik is a Physician Assistant at Terry Reilly Health Services. Here’s Mr. Bizik now.

Mr. Bizik:
The question about how GOLD has changed in the last few years is really important because it affects what we do every day when we see patients with COPD. Previously, we had four categories, A, B, C and D. Those categories allowed us to choose the best inhaler therapy for these patients based on exacerbation history and symptoms. Last year and this year, GOLD has really stepped back and said, “We need to prioritize exacerbations,” so they got rid of two letters of the alphabet. They got rid of C and D and combined them into one, and that is category E. So A and B are still very similar: patients that have one or fewer exacerbations and symptoms that are mild to moderate. But when you get into that category E now, we know those patients are having exacerbations either two a year or one that led to hospitalization. In those patients, GOLD said, “We really want to focus on exacerbations and preventing those,” and that’s why it’s category E, E standing for exacerbations and also eosinophils. For that last category of E, the primary focus is getting those patients on the appropriate therapy early in their care and preventing exacerbations, and when they do have an exacerbation, being very active in trying to get them better, reduce the total morbidity, get them out of the hospital faster if we can, reduce the risk of coming back to the hospital with a follow-up exacerbation, and then preventing future exacerbations. This has been the focus of GOLD the last couple of years and has really changed the way we approach treatment for patients with COPD.

So as GOLD reclassified patients, they made very specific recommendations for therapy. We’ve always had the short-acting beta agonists and muscarinic agents, and those still stay the same. That’s your first line for quick relief of dyspnea. The next categories though are looking at bronchodilators, like a long-acting beta agonist and long-acting muscarinic agents. The GOLD guideline changes have said for those patients that have more symptoms or more exacerbations, get them on a LABA/LAMA early. Get them on those therapies which reduce constriction and help them breathe better. Specifically, though, for those patients with higher eosinophil levels, that’s a subgroup that should be considered for an inhaled corticosteroid. Not everybody. In fact, GOLD makes a big point of saying, “For therapy, if they don’t need an inhaled corticosteroid, don’t give it to them.” You get all the side effects without the benefits, so we really want to appropriately give inhaled corticosteroids. Now, we have two triple inhalers, so those combine a LAMA, a LABA, and a steroid. So for those patients in category E that have elevated eosinophils—generally over 200, but certainly those over 300 should be considered—those patients really do well on a triple inhaler, and doing so helps prevent exacerbations.

GOLD has also added sections talking about personalized care, or as they talk about it, “treatable traits,” and I love that because patients come in now and it’s not just all COPD goes in one bucket. We’re asking questions like, “What are their eosinophil levels?” Every CBC that you get has the eosinophil levels. At least every one I get. Most people get those every time, so there’s usually a number of eosinophil counts in the chart already. If they’re elevated, I’m going to personalize their care and make decisions based on that. Also, “How frequently are they exacerbating?” Somebody who’s never really had one versus somebody who’s had two flare-ups in the last year, that’s a very different patient, and you’re going to go down a different pathway and maybe be more aggressive with prevention. And then the last treatable trait that GOLD talks about is just their dyspnea score. How much can they do? What can they not do? Can they go shopping? Can they not? Asking questions about the impact of COPD on their life helps you know how aggressive you need to be; what steps we need to take based on not just everybody but your specific treatable traits and biomarkers. In this case, the main biomarker we’re using is serum eosinophils.

Announcer:
That was Mr. Brian Bizik talking about the newest guidelines from the Global Initiative for Chronic Obstructive Lung Disease. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!