GOLD and how do they grade
they produce the standards of care for COPD
- the assessment of COPD stages assigns a grade (A,b,c,d) to guide initial COPD managementt
- creates a graded approach to COPD managment
- all of the drugs when studied across a wide range of patients at different severities
Assess exacerbation risk :
0-1 exacerbations without hospitalization
mmRc 0 to 1: act <10 = A
mMRC>2 ; CAT > 10: B
> 2 exacerbations or >1 hospitalization
mmRc 0 to 1; cat <10 : C
mmRC >2; CAT > 10: D
General measures for COPD treatment
1) smoking cessation
2) proper inhaler technique review
3) pulmonary rehabilitation and regular physical activity
4) vaccinations- influenza, pneumococcal, COVID
5) nutritioinio
Group A definition
minimally symptomatic and low risk of excerbations
Group A suggested treatment
Short acting bronchodilators- typically PRN
1) SABA - albuterol
2) SAMA - Ipratropium
3) SABA/SAMA - albuterol/ipratropium
Bronchodilators affect on group 1
they have been shown to improve sxs, exercise capacity, and airflow limitations
- note: some new evidence showing use of LAMA - better than the placebo, but still investigating long-term outcomes before expanding roles of LAMAs in these patients
Group B definition
Moderate to severely symptomatic with a low risk of exacerbations
Treatment of Group B
- Chronic, regular treatment with a long-acting bronchodilator
1) Most Common: LAMA - LAMAS may have a slightly greater effect at preventing exacerbations
2) Less Common: LABA monotherapy
3) For severe breathlessness (CAT ≥ 20) – may initiate LAMA+LABA combination
Group B ADRS
- Efficacy and safety are in general comparable across all LABAs and LAMAs – often decided on based on ADRs
1) LABAs – resting tachycardia, tremor
2) LAMAs – dry mouth, urinary retention
SYMPTOMATIC RELIEF GROUP B
include a short-acting bronchodilator for acute symptomatic relief (usually a SABA)
GROUP C DEFINITION
Mild or infrequent symptoms but high risk of exacerbation
GROUP C USE
1) Regular, chronic treatment with a LAMA
- Showed reduced exacerbation rates in this group – However, no statistically significant reduction in overall hospitalizations or mortality
- Another study showed that tiotropium versus salmeterol increased the time to the first exacerbation
- Another study tiotropium showed better protection against exacerbations over the next year when compared to indacterol
GROUP C ACUTE SYMPTOMATIC RELIEF
SABA
GROUP D DEFINITION
Moderate to severe symptoms and high risk of exacerbations
GROUP D USE
- Regular chronic treatment with a long-acting bronchodilator
Initial therapy with LAMA - For severe breathlessness (CAT ≥ 20) – may initiate LAMA+LABA combination
- Systematic review and meta-analysis of 10 trials– better quality of life, small increase in FEV1, reduced exacerbations
GROUP D ACUTE SYMPTOMATIC RELIEF
SABA
GOLD STRATEGY FOR GROUP D
- GOLD strategy suggests adding ICS in patients with frequent COPD exacerbations (≥2/year) and/or blood eosinophils ≥ 300 cells/microL
- Evaluate after 1-3 months for worsening symptoms, exacerbations, or failure of lung function to improve
SABA EXAMPLES
Albuterol (Ventolin, Proair, Proventil), levalbuterol
SAMA EXAMPLES
Ipratropium (Atrovent)
LAMA EXAMPLES
tiotropium, aclidinium, umeclidinium, revefenacin, glycopyrrol
LABA EXAMPLES
formoterol, olodaterol, salmeterol, arformoteroL
ADVERSE AFFECTS OF GROUP B LABA AND LAMAS
LABAs – resting tachycardia, tremor
LAMAs – dry mouth, urinary retention
