Dr Chris Cooper reviews the 2017 GOLD COPD update and provides insight into the most significant changes to clinical practice

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Read this article to learn more about:

  • the revised GOLD ABCD assessment tool
  • the importance of reviewing inhaler technique and considering comorbidities in people with COPD
  • audit suggestions for good practice.

Audit points

 

Embarking upon and persisting with a global initiative of any kind is admirable, and using the ‘best scientific information available’ in a non-biased manner is clearly a high standard to aim for.1 In an effort to meet this high standard, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) was launched in 1997, and published its first report in 2001. Since then, GOLD has had the enormous task of keeping its guidelines and reports both up to date and relevant to daily practice. The 2017 version of the GOLD Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease reflects a willingness to revise and refine recommendations—even modifying the very definition of COPD—to fully recognise the importance of host factors and environmental factors.1 My assessment is that the biggest overall change in the 2017 version of the report is an increased emphasis on more personalised treatment for patients with COPD.

Value-based healthcare

Most healthcare systems are currently evaluating what can be achieved for the funding available and the concept of value in healthcare has been widely discussed. As healthcare professionals we may all benefit from a better understanding of the outcomes that matter most to patients rather than focusing on test results;2 this philosophy is supported by the removal of spirometric grading in the stratification of patients into the GOLD ABCD groups,1 discussed later in this article. Ensuring that patients receive the most clinically effective and value-based care means starting with the basics to provide flu vaccination, pulmonary rehabilitation, and effective stop smoking support. Implementing these services would help prevent the development of the disease and provide treatment for those with COPD.3,4

Individualised treatment

Probably the most obvious change to the GOLD recommendations on combined COPD assessment is the separation of spirometric classification from the GOLD ABCD assessment tool. This change makes it possible to place a patient into one of the mutually exclusive groups based on symptoms (as assessed with the modified Medical Research Council [mMRC] questionnaire or COPD assessment test [CAT]) and exacerbation history alone.1 Many clinicians find these groupings to be somewhat arbitrary; however, the established group cut-offs are based on evidence, and the principle of considering patients as more or less symptomatic and more or less at risk of exacerbation is sound, particularly as these groupings can be used when choosing an appropriate treatment. Additionally, the recommendations to avoid any over-treatment with inhaled corticosteroids are to be embraced and taken seriously.5

The GOLD COPD report states that the duration of treatment for exacerbations with either glucocorticoids (prednisolone 40 mg) or antibiotics (when indicated) should be no longer than 5–7 days. This was previously worded as 5 days for prednisolone and 5–10 days for antibiotics, so the updated recommendation still leaves some scope for individualisation, but reflects the latest evidence and a degree of pragmatism in that the treatment durations are now identical.1

Inhaler technique

A welcome addition to the report is the section on the assessment and regular evaluation of inhaler technique.1 It is widely known that many patients perform badly when assessed on inhaler technique but, more worryingly, some healthcare professionals are also unable to effectively demonstrate inhaler technique.6 There has been no discernible improvement in the frequency of correct inhaler technique over the past 40 years,7 and recent increases in the numbers and types of inhaler device will likely make this problem worse. Strategies to try and improve inhaler technique, such as the straightforward ‘teach back’ method, are highlighted in the report, although it is acknowledged that education will not help all patients.1

Integrated care and complexity

The report now includes a very good section on hospital discharge following an exacerbation, which includes recommendations on stabilisation of clinical management prior to discharge, as well as good planning and communication for follow up in the community.1 I do not expect these recommendations to be contentious.

At least 70% of patients with COPD will have a comorbidity.8 Acknowledgement in the report of the complexities of multimorbidity and polypharmacy is therefore welcomed; the report includes a brief guide to the management of some of the more common comorbidities and can be used as a helpful checklist for a clinician caring for a patient who has COPD alongside another concurrent disease.1

Conclusion

The aims of the 2017 report are to be admired, in terms of their focus on high value and holistic care, and encouragement of tailoring both pharmacological and non-pharmacological therapy to the individual patient. The retention of the GOLD ABCD groups may not suit some, but increasing the focus on symptom assessment and risk of exacerbations to help decide on treatment, and moving away from spirometry test results, seems to be a sound principle.

Minor criticisms of the report may include the need for slightly more detail on the emerging evidence on e-cigarettes since their use is increasing so rapidly, or an acknowledgement of the need for more targeted research into the effect of exposure to other environmental factors on patients with COPD (particularly occupational exposures, air pollution, infections, and smoked drugs). However, from the start, the GOLD COPD report does include citations to research assessing its own guidance, and this openness and genuine willingness to refine the strategy based on real evidence should be applauded.

 

Audit points

written by Dr Chris Cooper

Suggestion A

Rationale: 

There is wide variation in current smoking rates for patients with COPD, and an increased prevalence of smoking in those patients living in more deprived communities9

Audit suggestions:

  • What is the prevalence of current smokers in my practice?
  • How many offers of support to stop smoking have been made to each smoker on the COPD register, in the last 12 months?

Suggestion B

Rationale:

The response to ICS (even higher doses) is poor in the majority of patients with COPD.10

Audit suggestions:

  • How many of my patients with COPD are currently on high-dose (1000 micrograms or more beclometasone equivalent per day) ICS inhalers?
  • What was the date of the last ICS dose-specific review (as opposed to general medication review)?

Suggestion C

Rationale:

Recording exacerbation history is a key part of assessing future risk of exacerbation in the GOLD ABCD assessment tool.1

Audit suggestion:

  • How many patients with COPD have their exacerbation history recorded at their most recent COPD review?

Suggestion D

Rationale:

The GOLD report stresses the importance of regular assessment of a patient’s inhaler technique.1

Audit suggestions:

  • What proportion of patients with COPD have a documented record of inhaler technique assessment or demonstration in the past 12 months?
  • For patients with suboptimal technique, is there a record of follow up to demonstrate an improvement?

COPD=chronic obstructive pulmonary disease; ICS=inhaled corticosteroids; GOLD=Global Initiative for Chronic Obstructive Lung Disease

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References

  1. Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease—2017 report. GOLD, 2016. Available at: goldcopd.org/gold-2017-global-strategy-diagnosis-management-prevention-copd/
  2. Porter M. What is value in healthcare? N Engl J Med 2010; 363 (26): 2477–2481.
  3. Zoumot Z, Jordan S, Hopkinson N. Emphysema: time to say farewell to therapeutic nihilism. Thorax 2014. DOI: 10.1136/thoraxjnl-2014-205667.
  4. Baxter N, Cooper C. Letters: COPD in Primary Care. Br J Gen Pract 2012; 62 (599): 290–291.
  5. Hunjan A, Smith K. PrescQIPP Bulletin 109—inhaled therapy in chronic obstructive pulmonary disease (COPD). PrescQIPP C.I.C, 2015. Available at: www.prescqipp.info/inhaled-therapy-in-copd/send/69-inhaled-therapy-in-copd/2365-b109-copd-update
  6. Baverstock M, Woodhall N, Maarman V. Do healthcare professionals have sufficient knowledge of inhaler techniques in order to educate their patients effectively in their use? Thorax 2010; 65: A117–A118.
  7. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016; 150 (2): 394–406.
  8. Franssen F, Rochester C. Comorbidities in patients with COPD and pulmonary rehabilitation: do they matter? Eur Respir Rev 2014; 23 (131): 131–141.
  9. Simpson C, Hippisley-Cox J, Sheikh A. Trends in the epidemiology of chronic obstructive pulmonary disease in England: a national study of 51804 patients. Br J Gen Pract 2010; 60 (576): 277–284.
  10. Barnes P. Corticosteroid resistance in patients with asthma and chronic obstructive pulmonary disease. J Allergy Clin Immunol 2013; 131 (3): 636–645.G

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