The 2023 GOLD Strategy Report: Changing How We Look at COPD

This article was written by Michael W. Hess, MPH, RRT, RPFT

For more than two decades, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) Strategy Report has been one of the key resources in the COPD world. The annual report reviews the major research publications from the previous twelve months and provides recommendations for the diagnosis, management, and prevention of COPD. Periodically, the GOLD report undergoes a “major” revision, where significant changes in how we treat this condition are advised.

The 2023 report is an example of such an update. The past few years have seen the results of major longitudinal studies enter the conversation that have the potential to permanently change how we view COPD. I spoke with Dr. Antonio Anzueto, a member of both the GOLD Science Committee and the COPD Foundation Medical and Scientific Advisory Committee, about what he thought some of the most significant changes in the new document were and how those changes could impact COPD care.

“NOT JUST 78-YEAR-OLD MEN”

The first item Dr. Anzueto mentioned was how the report takes a brand-new view of the very definition of COPD. “We’re now looking at the complexity of COPD, which involves not just cigarette smoking, but other exposures,” he told me, “Especially in children.” This has been a common theme since the publication of the recent Lancet Commission on COPD report and a similar piece published in the American Journal of Respiratory and Critical Care Medicine. Interestingly, it also resembles some of the very earliest attempts to define COPD, then described as “chronic, non-specific lung disease (CNSLC).” In that model, first published in 1961, respiratory issues arose from a single entity. The particular pathogenesis and presentation of the condition later in life would be affected by genetics and environmental exposures. While CNSLC is not a direct analog (for example, it also put asthma under its umbrella), the modern definition of COPD reflects that COPD can appear well outside the stereotype of an aged smoker. Dr. Anzueto highlighted that the new “face of COPD” should be someone in their early 50s (or even younger), who happened to smoke or was exposed to pollutants, and was more likely female.

THE EARLIER, THE BETTER

The new report also brings some clarity to a phenotype of COPD that has long been poorly understood. There is a certain cohort of people who have reductions in their FEV1 and FVC (along with known risk factors), but a normal FEV1/FVC ratio (without restrictive lung disease). These reductions are known as preserved ratio impaired spirometry, or PRISm. These people very often have the daily symptom burden and activity limitation of those with spirometrically confirmed COPD, but because they do not meet the formal diagnostic requirements, they are generally excluded from research studies and treatment algorithms. It has also historically been difficult to understand the significance of the diagnosis at all, as people diagnosed with PRISm can fluctuate between that status, formal COPD, and even normal spirometry.¹ “We didn’t know what to do with these people ten years ago,” Dr. Anzueto said. However, he states that studies using longitudinal studies like COPDGene, as well as study cohorts in Japan and Europe, suggest that as many as half of those diagnosed with PRISm develop COPD within five years. More importantly, those that do develop COPD tend to have more severe pathophysiology based on imaging studies. This appears to be another situation where early identification of people with symptoms can improve the trajectory of COPD later in life.

EASY AS A, B…E?

Recommendations for initial therapy post-diagnosis have also been majorly revised. “There is no role for ICS/LABA combination in initial therapy,” according to Dr. Anzueto. Previously, people who had high symptom burden (COPD Assessment Score > 10) and were at high risk of exacerbation were thought to potentially benefit from combination therapy with a long-acting bronchodilator (LABA) and inhaled corticosteroid (ICS). However, data from the ECLIPSE cohort suggest that eosinophil count is more likely to predict corticosteroid response than basic exacerbation frequency.² Thus, the C and D groups that made up the frequent-exacerbator section of the “GOLD Box” have been combined into one designated E to avoid confusion in future research. Initial therapy for this group aligns with the movement to start most people with COPD on dual-bronchodilator therapy with inhaled corticosteroids remaining an option for those with a blood eosinophil count over 300 cells/µg. Ongoing therapy is still managed using the treatable traits pathways focusing on exacerbation frequency and dyspnea (which may call for advancement to triple therapy), as in previous strategy updates.

REFINEMENTS AND UPDATES

Sections of the report that did not receive major overhauls still saw updates. The COVID pandemic has seen an uptick in the utilization of virtual pulmonary rehabilitation, thus an increase in the amount of data on its efficacy. According to Dr. Anzueto, the new report emphasizes the utility of “tele-rehab” even beyond the pandemic to reduce access barriers. The definition of an acute exacerbation is more formalized with a time window, based on the Rome Proposal consensus document published in late 2021.³ Finally, vaccine recommendations have been updated to include the new 20-valent pneumococcal vaccine, as well as the COVID vaccine and boosters, based on their efficacy in the COPD population.

CONCLUSION

“At the end of the day,” Dr. Anzueto told me, “What we hope [the new report] will do is get people to start talking about COPD earlier, not wait until the disease begins to flourish.” Considering the longstanding problems of underdiagnosis and diagnostic delay, the new GOLD report updates should be a boon to advocacy and awareness efforts. In addition, by better understanding the origins of COPD and more accurately defining phenotypes, more effective research trials can be conducted, leading to better prevention strategies, better therapies, and one day, perhaps a cure. You can view the 2023 Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease at the GOLD website, https://www.goldcopd.org.