Treatment of Stable Chronic Obstructive Pulmonary Disease: the GOLD Guidelines



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Am Fam Physician. 2013 Nov 15;88(10):655-663.

  Related editorial: Choosing the Right Inhaled Medication Device for COPD

  Patient Information: A handout on this topic is available at http://familydoctor.org/familydoctor/en/diseases-conditions/chronic-obstructive-pulmonary-disease/treatment.html.

This version of the article contains supplemental content.

This clinical content conforms to AAFP criteria for continuing medical education (CME). See the CME Quiz.

Author disclosure: No relevant financial affiliations.

Chronic obstructive pulmonary disease (COPD) is a common problem in primary care. COPD is diagnosed with spirometry only in clinically stable patients with a postbronchodilator forced expiratory volume in one second/forced vital capacity ratio of less than 0.70. All patients with COPD who smoke should be counseled about smoking cessation. Influenza and pneumococcal vaccinations are recommended for all patients with COPD. The Global Initiative for Chronic Obstructive Lung Disease assigns patients with COPD into four groups based on the degree of airflow restriction, symptom score, and number of exacerbations in one year. Pulmonary rehabilitation is recommended for patients in groups B, C, and D. Those in group A should receive a short-acting anticholinergic or short-acting beta2 agonist for mild intermittent symptoms. For patients in group B, long-acting anticholinergics or long-acting beta2 agonists should be added. Patients in group C or D are at high risk of exacerbations and should receive a long-acting anticholinergic or a combination of an inhaled corticosteroid and a long-acting beta2 agonist. For patients whose symptoms are not controlled with one of these regimens, triple therapy with an inhaled corticosteroid, long-acting beta2 agonist, and anticholinergic should be considered. Prophylactic antibiotics and oral corticosteroids are not recommended for prevention of COPD exacerbations. Continuous oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD. Lung volume reduction surgery can improve survival rates in patients with severe, upper lobe–predominant COPD with heterogeneous emphysema distribution.

Chronic obstructive pulmonary disease (COPD) is a common problem in primary care. The estimated prevalence is 6.3% (15 million persons) in the United States,1 with more than 126,000 deaths each year.2 COPD treatments aim to improve quality of life and control symptoms while reducing exacerbation risk, which can lead to increased morbidity and mortality.

This article summarizes expert consensus guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD) for nonpharmacologic and pharmacologic interventions for patients with stable COPD.3 The GOLD guidelines are widely used in the management of COPD. (Disclosure: the GOLD program is funded by pharmaceutical companies that make medications for COPD, and the board of directors, committee members, and reviewers have ties to the pharmaceutical industry. See http://www.goldcopd.org/disclosure-statements.html.)

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Suspected COPD should be confirmed by spirometry in stable patients with a postbronchodilator forced expiratory volume in one second/forced vital capacity ratio of less than 0.70.

C

3

Smoking cessation is recommended for all patients with COPD who smoke.

C

14, 15

Patients in GOLD group A should be treated with a short-acting anticholinergic or short-acting beta2 agonist on an as-needed basis.

A

1921

Patients in GOLD group B should be treated with a long-acting anticholinergic or long-acting beta2 agonist.

A

2229

Patients in GOLD group C or D should be treated with a long-acting anticholinergic or a combination of an inhaled corticosteroid and long-acting beta2 agonist.

B

3, 24, 28, 34, 37, 38

Long-term oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD.

A

42, 43


COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

View Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation Evidence rating References

Suspected COPD should be confirmed by spirometry in stable patients with a postbronchodilator forced expiratory volume in one second/forced vital capacity ratio of less than 0.70.

C

3

Smoking cessation is recommended for all patients with COPD who smoke.

C

14, 15

Patients in GOLD group A should be treated with a short-acting anticholinergic or short-acting beta2 agonist on an as-needed basis.

A

1921

Patients in GOLD group B should be treated with a long-acting anticholinergic or long-acting beta2 agonist.

A

2229

Patients in GOLD group C or D should be treated with a long-acting anticholinergic or a combination of an inhaled corticosteroid and long-acting beta2 agonist.

B

3, 24, 28, 34, 37, 38

Long-term oxygen therapy improves mortality rates in patients with severe hypoxemia and COPD.

A

42, 43


COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive

The Authors

HOBART LEE, MD, is the program director and an assistant professor of family medicine at Loma Linda (Calif.) University School of Medicine.

JEFFREY KIM, MD, is the assistant program director and an assistant professor of family medicine at Loma Linda University School of Medicine.

KARINE TAGMAZYAN, MD, is a fourth-year combined family medicine and preventive medicine resident at Loma Linda Inland Empire Consortium for Healthcare Education.

Address correspondence to Hobart Lee, MD, Loma Linda University School of Medicine, 25455 Barton Rd., Ste. 209B, Loma Linda, CA 92354 (e-mail: holee@llu.edu). Reprints are not available from the authors.

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