COPD: A review of what’s new in the updated GOLD guidelines

COPD: A review of what’s new in the updated GOLD guidelines

good afternoon everyone thank you for
joining me for this quick update on the newest gold COPD guidelines as you may
recall in an effort to standardize care for patients with COPD the National
Heart Lung and Blood Institute and the World Health Organization introduced the
global initiative for chronic obstructive lung disease or gold
guidelines in 2001 these guidelines are updated yearly in our evidence base the
2017 version included some significant changes I would also like to alert you
if you have questions for me throughout go ahead and enter those in the question
side of your screen so our objectives for this webinar include a very brief
review of COPD including the definition prevalence and risk factors I’ll briefly
talk about assessment tests that you’ll see mentioned in the guidelines like the
COPD assessment test and the modified Medical Research Council respiratory
questionnaire I’ll give you the guideline update mainly focusing around
the ABCD risk classification grading system and then how to treat patients in
each stage of that ABCD grading system and I can also take questions so as you
probably remember from school COPD is a persistent airflow limitation brought on
by chronically inhaling noxious particles or gases most patients present
with shortness of breath or productive coughs remember patients should be
evaluated for COPD if they have risk factors any type of shortness of breath
chronic cough or sputum production the number one risk factor in the u.s. is
smoking cigarettes but in other parts of the world in here inhaling biofuels and
pollution are major factors other risk factors include a family history low
birth weight childhood respiratory infections the incidence and prevalence
is probably higher than you would guess and vary significantly throughout the US
according to the Centers for Disease Control and Prevention or the CDC the
lowest prevalence in States ranges from 3 to about 4% the prevalence in Missouri
however and suffer other high prevalence dates can range
from seven to nine percent the incidence and prevalence of COPD is expected to
continue to rise as the population ages and people continue to smoke
although COPD was the sixth leading cause of death in 1990 it’s estimated
that it will actually be the third leading cause of death worldwide by 2020
so the staging of COPD into mild through very severe has not changed
you may remember what stage a patient is characterized categorized into will be
determined by their pulmonary function test so their post bronchodilator fev1
to FEC ratio will be less than 70 and then you look at the post bronchodilator
se v1 so just a reminder if it’s greater than 80 that’s considered mild or stage
150 280 is moderate stage to 30 to 50 severe stage three and then less than 30
is very severe or stage four the guidelines mentioned several tools for
assessing the impact that COPD is having on a patient’s life the two most
commonly used in practice and research are the COPD assessment test or the cap
score or the modified medical research council questionnaire often seen as the
MMRC both our brief questionnaires and our self administered either one can be
used when assessing a patient’s risk stratification which we cover shortly so
gold continues to refine its ABCD grading system that they first
introduced in 2011 the ABCD grading system considers both COPD symptoms
along with exacerbation frequency and severity and to remind you a is better B
is worse before this update pyrometry was a component of the ABCD grading
system probably the biggest change with the 2017 update is the separation of
symptom evaluation from spirometry results so separating spirometry from
the ABCD risk stratification was done because it’s been shown that airflow
limitation or PSP results correlates less well with functional limitation and
quality of life than patient reported symptoms and exacerbation history
pyrometry is still the gold standard for diagnosis and should be performed in
patients so moving from the left-hand side of this slide we see the spirometry
confirms a COPD diagnosis and an assessment of airflow limitation is made
same as always patients are then categorized as either
gold one through four so mild through very severe based on those PSP results
now separate from that we still want to assess a patient’s based on their
symptoms risk for future exacerbations and the effect of the disease has on
their overall health when we do that by categorizing them into a risk grade of a
B C or D so I think a patient example might actually help here so we’ve got
Bob a 58 year old male with COPD complaining of chronic productive cough
he’s been smoking a pack a day since he was 18 and is sent for
pulmonary function tests you can see his results on the slide so Bob in fact does
have COPD based on this fev1 2sec ratio that remains less than 70 after
bronchodilators and we would actually assess them as gold stage to moderate
because his post fev1 his post falco dilator fev1 is between 50 and 80%
predicted now let’s assess his risk stratification score so God tells us
he’s had one exacerbation in the past year treated as an outpatient with an
oral steroid verse and a round of oral antibiotics his Katz court today is nine
therefore he would call he would fall into risk category a if he had worse
symptoms so a cat score greater than 10 or more exacerbations this could have
pushed him into a different category so why are the ABCD risk stratification
levels necessary why did the guidelines put so much emphasis on this now the
guidelines recommend medications for treating patients based on where they
fall in this ABCD grading scheme when treating patients the emphasis should be
placed on meds that can help improve symptoms that also prevent future
exacerbations so this is an overview of guideline recommended treatments for
patients in each category and we’re going to go through each one
of these separately before I do that I just briefly wanted to mention and make
sure that we’re all on the same page regarding terminology in terms or
abbreviations that I use so asada is a short-acting beta agonist a lava is a
long-acting beta agonist like a salmeterol or formoterol Asama is a
short-acting muscarinic antagonist like it’s appropriate a llama
is a long-acting muscarinic antagonist an example of that would be tiotropium
ICS stands for inhaled corticosteroid so like your fluticasone dexamethasone
bhujette nine ICS lava those are your inhaled corticosteroids
long-acting beta agonist combo so like add their ICS llama cut is an inhaled
corticosteroid long-acting muscarinic antagonist and then a lobby llama is
your long-acting beta agonist long-acting muscarinic antagonist so
starting with group a remember our patient Bob with Group A these patients
can be appropriately treated with a bronchodilator that could actually be a
Saba or lava group B patients when you’ve got patients that fall into Group
B initially they should be placed on a long-acting bronchodilator there’s
really no evidence to recommend one class of long-acting bronchodilator over
another so that initial release relief of symptoms in the individual patient
the choice should depend on the patient’s perception of symptom relief
so our options here are going to include lavas so salmeterol for motor all the
NED versions of for motor all olodan are all would be options or you could do a
llama so tiotropium ecwid inium you neckla
diem or bike up i relate now if pages patients in Group B remain symptomatic
on one drug you want to add a drug from another class for dual drug therapy for
patients with severe breathlessness initial therapy with two bronchodilators
can be considered if the addition of a second pro cosine later does not improve
symptoms the guidelines are actually now recommending that you revert back to
mono therapy only so this is really the first
I’m the gold guidelines really talk about the escalation of therapy or
stepping down is symptomatic improvement isn’t reached so to remind you patients
in Group C or D things are going to be our patients with more frequent
exacerbations and worse than some scores which leads to poor overall quality of
life so for our patients that’s all in a group C guidelines that recommend
starting with a single long-acting bronchodilator and they’re actually
going as far as to recommend llamas and so remember our llama options are going
to consist of that tiotropium ecwid idiom you neckla diddy AMARG like hope i
relate and they may recommend starting with llamas because in two large
head-to-head comparisons the tested llama was better than the lava to win
preventing exacerbations now if patients have persistent exacerbations they can
benefit from adding a second long-acting bronchodilator so you would go to that
lava llama combo or you could use a combo of the long-acting beta agonist
and an inhaled steroid so that would be your lava ICS now remember ICS can
increase the risk for developing pneumonia in some patients and so the
guidelines recommend is their primary choice
the lava llama combo and remember are available we do have some lava lama
combo available in the same device so Teatro Priam combined with olodan troll
and that’s the ski also rest on it another option is you method idiom and
Vilanch RL that’s the anoro ellipta glyco pyro light in Endicott roll or the
UD Braun neo hailer and then glyco pyro light formoterol which is the new
Bethesda Aero sphere so our group D patients are probably the hardest to
treat right these are going to be our patients with severe symptoms that
impacts their overall quality of life and their overall health but they’re
also experiencing frequent COPD exacerbation so preventing future
exacerbations has really been an outcome of research for COPD drugs for a long
time and keeping patients out of the hospital you know not only reduces costs
but also impacts the patient’s overall morbidity and mortality for group B
group D patients guidelines recommend a llama llama combo is the place to
start it’s been shown in studies that with patient reported outcomes as the
primary endpoint that lava llama combos shows superior results compared to using
the single substances so as a single bronchodilator is chosen as initial
therapy again the guidelines are going to recommend going with a llama over a
la lava because they prevent exacerbations better also lava llama
combo was superior to lava ICS combo in preventing exacerbations and other
patient-reported outcomes in this group the patient population also to add a
little bit more fuel to this fire group D patients are actually going to be at
higher risk of developing pneumonia when receiving treatment with an ICS so in
some patients initial therapy with a lava ICS may be the first choice these
patients may have a history and possibly other findings suggestive of the asthma
COPD overlap syndrome and this asthma copd overlap syndrome is also covered in
the 2017 guidelines update but unfortunately we don’t have time today
to review that particular topic high blood elf initial counts may also
be considered as a parameter to support the use of ICS in these patients
although this is still currently under debate
so in patients who develop further exacerbations on lava llama therapy the
guidelines give us two alternative choices the first is you can escalate to
a lava lama ICS and so studies are currently underway comparing the effects
of dual therapy versus triple therapy so we’re trying to figure out which is
better lava llama or lava lama ICS in preventing exacerbations or the second
choice is to switch to lava ICS now I do want to point out there’s really no
evidence to support switching from lab there’s no evidence that says if you
switch from lava lama to lava ICS you’re going to have better COPD
exacerbation prevention also if that lava ICS therapy is is patients are
still having exacerbations you would still consider adding a llama later also
as a reminder available ICS lava lama combos are not currently FDA approved
however there are two in the pipeline they include the first is dude S&I
formoterol and glyco pyro Neum and that will probably be in an HSA device and
the second is fluticasone 0-8 with Volant Rahl and you neckla din IAM and
that will be a neo lifted device I anticipate that they will both have once
daily dosing which is kind of nice a three drug combo with once a day just
once a day joking so if patients treated with that lava ama ICS still have
exacerbations the following options can be considered that’s when we could
potentially add row’ Fuma laughs so this may be considered in patients if they
have an fev1 less than 50% predicted chronic bronchitis and it particularly
if they had in at least one hospitalization for an exacerbation in
the last year the other choices you could you could potentially add a
macrolide the best available evidence here is going to be for the use of
azithromycin I personally haven’t seen this done but you know make sure patient
providers are aware that they need to consider the possibility of resistance
if they go this route the other option would be to get rid of the ICS so you
know if it’s not helping they’ve got an increased risk of adverse effects
especially pneumonia and you know there’s really no harm in taking an ICS
away so you know that could also help support that recommendation so let’s
briefly look at a patient example so we’ve got a patient newly diagnosed and
that falls in the category C so remember those are going to be patients and that
forcing symptoms frequent exacerbations and remember remember preventing
exacerbations in this population is key and so you know guidelines recommend
starting with the llama our choices would be the tiotropium you neckla
divyam academia Organic like oppai relate if patients have still further
exacerbations on a llama mono therapy that’s when we would switch to dual drug
combo lava lama so the take-home point here really is that this is different
from previous editions of the guidelines we used to push ICS labas to prevent
exacerbations the push now is to get folks on llama agents again
they’re going to have better exacerbation prevention data and less
than on your wrists with youth also de-escalation of therapy if patients
don’t respond or exacerbation frequency doesn’t improve remove that newly added
agent no benefit plus if it’s not cost-effective and it may be adding to
inhaler burden these are all justifications for getting rid of that
second agent I do just want to at least mention that this guideline update
definitely reflects the vast improvements in COPD therapies that are
now available when I went to school there were probably only a handful of
meds for COPD I remember albuterol if it’s short gram and there might even add
in a lava I’m not sure this update is also reflective of the latest evidence
from multiple large randomized controlled clinical trials which is
great because all pharmacists love evidence-based medicine however some of
these newer agents for example combination inhalers and the newer
devices don’t come without cost of course a once-daily drug and combining
drugs from different classes into one inhaler can improve adherence and
outcomes but only if the patient can use it correctly and afford it the best
inhaler is the one that patients can understand can afford and will use
regularly I did want to briefly mention monitoring of our COPD patients because
I see a role for pharmacist year in order to appropriately decide whether to
adjust therapy it should be determined as patience or adherence to their meds
using their inhaler correctly and experiencing adverse effects among other
things educating patients on the importance of adherence and why it’s
important to take medications can be done when dispensing refills the
guidelines actually now state and inhaler techniques should be
demonstrated to all patients and their technique confirmed before deeming a
medication is not effective so who better to do that than us the medication
experts documenting if a patient is experiencing an adverse effect also
falls into pharmacist expertise so what can we as pharmacist do you know really
get out there and talk to patients about nonfarm therapy help them understand the
importance of quitting smoking and linking you know continued smoking with
worsening pulmonary function making sure patients are up to date on their
immunizations and then hitting device technique you know at
first sale subsequent sales and using that show me and teach-back method to
really be able to assess if patients are using their inhalers correctly and then
also encouraging close follow-ups with their providers I hope you enjoyed this
brief guideline update to summarize major changes include separating
pulmonary function test results out of the mix when assessing patients into
that ABCD grading system there are changes and treatment recommendations
now based on those ABCD grading system an emphasis on preventing exacerbation
to remember you get better evidence with llamas versus lavas ICS therapy can
increase pneumonia rates especially in our sicker patients so is it for example
those that fall into category DS and dogs the escalation of therapy is
warranted if no symptomatic improvement or the frequency of the exacerbation
rate is not improved again this is the first time the guidelines really talk
about stepping down or getting rid of medications and then also patients in
Group C and D I do want to at least say that you know those recommendations are
probably likely to continue to change in the future as more and more of these
large clinical trial data becomes available
and lastly regular attempts should be made to assess patients device technique
with that I will entertain any questions that anyone has so I don’t see any um I don’t see any questions so I think that
concludes our broadcast Thanks


  1. Min 9.40…I think you mean tiotropium has shown better effect on exacerbation, not LAMA in general. The algorithm is flawed. Until further proof the recommendation should be tiotropium.

  2. Plus they chose to take out of the therapeutic algorithm FEV1, while now in groups C and D one severe exacerbation equals to 3 for example exacerbation and 30% FEV1…Not enough data on frequent exacerbators. I wonder why they made such a big change in 1 year only without sufficient data.

  3. You can also be diagnosed with this when you have diarrhea and have the flu…my life was a nightmare for 3 years because of being wrongly diagnosed. I hope if you are nurses you pay attention to the patient…I have great insurance through my employer, I feel it was a big sign, to abuse also. As, much as people with copd are not diagnosed, they are a lot that are diagnosed and they do not have it. And, why isn't there a cure for a disease that killed Henry the VII in the 15th century…if I was in the medical field I'd be ashamed of this, not giving people stigma. Smokers are stigmatized, whilst opioid addicts who leave their kids starving, dirty alone you save them over and over and over again. Explain that, in a vlog. I have become enraged after seeing what you do to people. This is a greed driven disease, that's the reason it's not cured, it pads a lot of pockets. The medical community can not have any better advancements ? Diagnostic ability, spiriomety is usually given by someone who hasn't a clue what there doing….finally I was told to take a deep breath and blow..thats a big difference, and demanded a CT scan…thank God I'm persistent. But, if your dealing with Copd patients they are humans, they will probably out live half of you. Have you seen them on threadmills?? They are health freaks, and they are germ phobic….I'm betting on them. Find a cure…do something…

  4. I grew up with asthma; I suffered sinus and respiratory infections my entire life. I started smoking at 16. When I was in my early 40s, my asthma was becoming increasingly worse. I was diagnosed with COPD at age 47. I am now 55. I quit smoking four years ago. The disease does not improve. My good days were far,i was scared that i wont survive it but i was so lucky to receive a herbal products from my step father who bought it while coming from South Africa for Rugby league,this herbal remedies saved me from this disease,at first it helps fight the symptoms of diseases and i was seeing good outcome,i had to use it for 13 weeks just as they Dr was prescribed and i was totally cure of asthma and COPD, (Totalcureherbalfoundation gmailcom) do not hesitate to purchase from them they deliver across worldwide to

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  5. I have been diagnosed COPD and chronic emphysema and also the antitrypsin deficiency for over 12 years. My principal symptom has been a heavy feeling in the chest. I cannot breathe well while lying flat on my back or on my right side.
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  6. I was diagnosed as Chronic obstructive pulmonary disease(COPD) carrier after tests were done to investigate my immune system. I had Chronic obstructive pulmonary disease (COPD) of the Lungs already present. I started treatment with Bronchodilator which Helps open the airways of the lungs to make breathing easier and Steroid which Modifies or simulates hormone effects, often to reduce inflammation or for tissue growth and repair. After a couple of years the virus became resistant and i decided to try a more natural approach to treat the virus, so i started on Chronic obstructive pulmonary disease(COPD)Herbal formula treatment from solutions health herbal clinic, this natural (COPD) treatment totally reversed my condition. I did another blood test after the 2 months treatment and tested negative to the virus. Go to solutions health herbal clinic official email [email protected] This treatment is a breakthrough for all (COPD) carriers.Their natural herbs are very effective and cure your (COPD) permanently.

  7. For the past few years I have had difficulty working out in yard and carried a lawn chair with me. Then a couple of months ago it got harder and harder to breathe. After many tests it was a CT scan that showed COPD, emphysema and scarring in my lungs. I quit smoking 12 years and 6 months ago. But they told me the damage has been done. I got to the point I couldn't catch my breath and was coughing so hard I thought the top of my head would blow off. The day after I had the scan I was on oxygen the next night and am on it 24/7. I can take it off to shower and take a few minutes break now and then. Even though I was tethered to the machine or tank I carry when I'm out, I am very thankful for total cure herbal foundation who I we bought the COPD Emphysema from, the COPD herbal treatment cured me totally and reversed all symptoms, our family DR provided us their website where to order the herbal products from because the COPD Herbal formula is 100% Natural organic herbs and MCC approved that was why we had to trusted and give a try on it,I have an understanding family and even though it is entirely my fault they want me to live as long as I can. Visit their website and order or chat with the online Doctors
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  8. I’m not in the medical industry but I could follow this presentation because the présenter was so clear, engaged and precise in her delivery. Thank you!

  9. Um… it’s STILL true: SMOKING causes C.O.P.D. But you IDIOTS knew that….since your FIRST cigarette. Ha!!!!!

  10. One of my friend was suffering from COPD. His condition was
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  11. I'm struggling a lot with exharsebations in a daily basis. My current lung function is about 30%. I have a permanent dual pacemaker. My hands and feet are often blueish. I'm tired nearly all the time. I'm wheezing a lot and have to tell myself not to sleep most or all of the day. I was diagnosed in 2016. My FEV1 was 47% a year ago and it's now 30%.

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