2023 GOLD report reflects COPD field that is ‘improving on a trajectory for the better’

The 2023 Global Initiative for Chronic Obstructive Lung Disease report defines several changes regarding definitions, assessment tools and treatments for COPD, all of which underscore recent advances in the field.

“COPD is not a stagnant disease,” Gerard J. Criner, MD, FACP, FACCP, director of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) International COPD conference, told Healio. “The report identifies disease-modification therapies because we’re improving outcomes and we’re changing mortality, which should give patients and clinicians hope that the field is improving on a trajectory for the better.”

To learn more about the updates made in the 2023 GOLD COPD report, “Global Strategy for the Diagnosis, Management and Prevention of COPD,” Healio spoke with Criner about the key changes that were presented at the conference.

Revised definitions, assessments

One overarching significant change in the report is a revised definition of COPD that is more all-encompassing of the demographic that can develop COPD, according to Criner, who also serves as chair and professor of thoracic medicine and surgery at Lewis Katz School of Medicine at Temple University.

“The modification of the definition acknowledged that it’s not just people who have been exposed to cigarette smoke but other types of exposures, such as biomass fuels,” Criner said. “The definition also includes people who work in jobs that expose them to a variety of conditions or poor climate. Additionally, it addresses a variety of host factors that may occur in the U.S., as well as non-U.S., such as being born premature or having a lot of childhood infections.”

Along with this change in definition, the report also gives more attention to the roles chronic bronchitis and mucus hypersecretion play in the development of COPD and the pathogenesis of airflow obstruction.

The 2023 report also has more information on the role of imaging and CT in diagnosing and managing COPD, highlighting the fact that CT has become increasingly available, leading to greater understand of COPD phenotypes, severity and outcomes. The report specifically recommends considering CT for patients with COPD and:

• persistent exacerbations;
• symptoms that exceed disease severity based on lung function testing;
• FEV₁ less than 45% predicted with significant hyperinflation;
• who meet criteria for lung cancer screening.

“We have written more about imaging and the importance of imaging to detect abnormalities that may exist in people with COPD that doesn’t cause airflow obstruction in its earlier stages,” Criner said. “The changes reflect that the importance of imaging is more ubiquitous, especially since the imaging with lung cancer screening and people who have been smoke-exposed determine structural abnormalities that may occur and may indicate people who are at greater risk to develop airflow obstruction.

“The hope is to determine factors that may contribute to COPD earlier in life, so we can intercede and maybe transform the development or alter the trajectory,” he added.

Another important change in this year’s report is a switch from using the “ABCD Assessment Tool” to the “ABE Assessment Tool.” Groups C and D from the original tool are now combined into group E, representing patients who have a record of either two or more moderate exacerbations or one or more exacerbations that resulted in hospitalization.

Criner told Healio this change makes for a more clinically relevant explanation of exacerbations.

“This makes it simpler for a clinician, and if a patient has frequent exacerbations or has elevated peripheral blood eosinophil levels, then perhaps those patients should be added on an inhaled corticosteroid,” Criner said. “That’s based on more recent randomized control trials.”

COPD management

The report also contains details on the management of stable COPD with both pharmacologic and nonpharmacologic treatments to reduce symptoms and future risk for exacerbations.

When discussing long-acting bronchodilators, Criner said another key change in the report is that it now recommends long-acting muscarinic antagonist (LAMA)/long-acting beta-agonist (LABA) combination therapy for most patients (Groups B and E) as initial therapy, with bronchodilators recommended for patients in Group A. With this update, the combination of LABA and an inhaled corticosteroid (ICS) is no longer recommended.

“Based on more recent data from randomized control trials, we suggest that the initial use of long-acting bronchodilators in patients who are more symptomatic or exacerbation prone is warranted,” he said.

Criner also told Healio that the 2023 report includes findings from two recent randomized clinical trials, IMPACT and ETHOS, which found that inhaled triple combination therapy of LABA, LAMA and ICS reduced all-cause mortality.

“The use of triple inhaled therapy joins other therapy for select patient populations with COPD, such as long-term option, lung volume reduction surgery, smoking cessation and use of noninvasive ventilation,” Criner said. “Triple inhaled therapy in that select group of patients prone to moderate and severe exacerbations has a mortality benefit.”

More information also was added to the report on the topics of preventive and surgical treatment of COPD emphysema.

“It’s more robust in not only talking about therapies that are available, but therapies that are currently undergoing phase 3 trials, both U.S. and non-U.S., that may be applicable to patients with COPD, exacerbations or chronic mucus hypersecretion,” he said. “There is also more detail on the patient populations and treatments that lung transplant may offer patients with COPD and emphysema.”

The latest evidence on COPD in relation to comorbidities — which commonly include cardiovascular diseases, lung cancer, osteoporosis, depression/anxiety and gastroesophageal reflux and, in general, should not change COPD treatment — and COVID-19 were also featured in this report, Criner said. Regarding COVID-19, the report includes guidance on when patients with COPD should be tested for COVID-19, maintaining treatment throughout the pandemic and when it is appropriate to use spirometry and remote patient follow-up.

Looking ahead

When asked about the key takeaway for doctors and clinicians in the field, Criner said the 2023 report strives to improve the health of patients with COPD in several ways.

“We’re trying to move the field to look at it more encompassing of patients’ health by trying to define factors both in = and outside of the lung that are modifiable and treatable so we can overall further improve cases,” he said.

For next year’s conference, Criner said he would like to target patients as well as more primary care physicians and pulmonologists.

“The conference is geared toward translating it into clinical practice, but it still doesn’t reach the primary care physician or perhaps the busy clinical pulmonologist,” he said. “We’ll try to address that audience by spreading out the conference to more than 1 day, targeting areas based for the community physician, and overall try to digest this, bring it to the patient and make it more relevant.”

For more information:

Gerard J. Criner, MD, FACP, FACCP, can be reached at gerard.criner@tuhs.temple.edu.

References:

• Venkatesan P. Lancet Respir Med. 2022;doi:10.1016/S2213-2600(22)00494-5.
• 2023 GOLD report. Global Initiative for Chronic Obstructive Lung Disease. https://goldcopd.org/2023-gold-report-2/. Published Nov. 16, 2022. Accessed Dec. 7, 2022.