Professor David Halpin highlights key learnings for primary care from the updated GOLD strategy for chronic obstructive pulmonary disease

halpin david

Professor David Halpin

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Read this article to learn more about:

  • assessment, diagnosis, and management of suspected chronic obstructive pulmonary disease
  • follow up of pharmacological and non-pharmacological therapies
  • personalising patient education
  • differential diagnoses of exacerbation symptoms.

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Chronic obstructive pulmonary disease (COPD) remains a major cause of morbidity and mortality in the UK. The British Lung Foundation’s Respiratory Health of the Nation project estimated that, in 2016, 1.2 million people in the UK—4.5% of all people aged over 40—were living with diagnosed COPD.1 The research underpinning the project also showed that the prevalence of COPD had increased by 27% over the previous decade.1 NICE published a further partial update to its guidance on the diagnosis and management of COPD (NICE Guideline 115, Chronic obstructive pulmonary disease in over 16s: diagnosis and management) in July 2019,2 but many clinicians and formularies rely on the management recommendations produced by the Global Initiative for Chronic Obstructive Lung Disease (GOLD), which are more regularly updated and more easily applied in practice than the NICE recommendations. In November 2019, GOLD published the 2020 update of its report on the management of COPD.3 This builds on the changes introduced in the major update in 20174 and the significant changes to pharmacological treatment recommendations made in the 2019 report.5 This article focuses on five key areas in which there have been important updates in the 2020 report that are relevant for clinicians working in primary care.

1. Remember the importance of the initial assessment and holistic management

Correct diagnosis of COPD and adequate assessment of the impact of the disease on individual patients are essential to ensure that they receive optimal management (see Figure 1).

At diagnosis, patients should have an assessment of:

  • severity of their airflow limitation
  • symptoms (using either the COPD Assessment Test™ [CAT™]6 or Modified British Medical Research Council [mMRC] Questionnaire7)
  • history of exacerbations
  • exposure to risk factors, e.g. smoking, indoor and outdoor air pollution, occupational exposures
  • alpha-1 antitrypsin level
  • co-morbidities.

After a suitable interval, the following should be reviewed:3

  • current level of symptoms (using either the CAT™ or mMRC)
  • exacerbation frequency
  • effect of treatment
  • possible adverse effects
  • co-morbidities.

Pharmacological and non-pharmacological therapy should be adjusted as necessary and further reviews undertaken.

Figure 1 Management of COPD

Figure 1: Management of chronic obstructive pulmonary disease3

FEV1 =forced expiratory volume in 1 second; CAT™=COPD Assessment Test™; mMRC=modified British Medical Research Council; GOLD=Global Initiative for Chronic Obstructive Lung Disease; NIV=non-invasive ventilation

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

Asthma and COPD

The GOLD report no longer refers to asthma and COPD overlap. It should be noted that:3

  • asthma and COPD are different disorders, although they may share some common traits and clinical features (e.g. eosinophilia, some degree of reversibility)
  • they may coexist in an individual patient
  • if a concurrent diagnosis of asthma is suspected, pharmacotherapy should primarily follow asthma guidelines, but pharmacological and non-pharmacological approaches may also be needed for the patient’s COPD.

2. Initiate and follow up pharmacotherapy

There are no fundamental changes to the recommendations on initial and follow-up pharmacotherapy in the GOLD 2020 report, but more detailed recommendations are made on the place of inhaled corticosteroid (ICS) therapy in COPD. Triple inhaled therapy of long-acting beta2 -agonist (LABA), long-acting muscarinic antagonist (LAMA), and ICS (i.e. LABA/LAMA/ICS) improves lung function, symptoms, and health status and reduces exacerbations compared with LABA/ICS, LABA/LAMA, or LAMA monotherapy.3 The effect of triple therapy in reducing mortality in high-risk patients is also recognised3 and, conceptually, this is a huge advance in the understanding of the benefits of therapy.

Initial pharmacological treatment

Initial pharmacotherapy should be based on the patient’s GOLD group (A–D; see Figure 2) determined by the:

  • level of symptoms (assessed using either CAT™ or mMRC) and
  • number and severity of exacerbations in the last year.

Figure 2 Initial pharmacological treatment

Figure 2: Initial pharmacological treatment3

LAMA=long-acting muscarinic antagonist; LABA=long-acting beta2 -agonist; ICS=inhaled corticosteroid; CAT™=COPD Assessment Test™; eos=blood eosinophil count in cells per microlitre;    mMRC=modified British Medical Research Council Questionnaire

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

Follow-up pharmacological treatment

Treatment can be escalated/de-escalated (see Figure 3) based on:3

  • the presence of breathlessness and exercise limitation
  • the continued occurrence of exacerbations
  • blood eosinophil count.

Figure 3 Follow-up pharmacological treatment

Figure 3: Follow-up pharmacological treatment3

LABA=long-acting beta2 -agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid; FEV1 =forced expiratory volume in 1 second

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

ICS treatment or not?

When deciding whether or not to initiate ICS therapy, the following factors should be considered (see Figure 4):

  • frequency of exacerbations
  • hospitalisation for an exacerbation
  • blood eosinophil count
  • history of or concurrent asthma
  • history of repeated pneumonia
  • history of mycobacterial infection.

Figure 4 Factors to consider when initiating ICS treatment

Figure 4: Factors to consider when initiating ICS treatment3

ICS=inhaled corticosteroid; COPD=chronic obstructive pulmonary disease

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

Recent trials utilising triple combinations of LABA/LAMA/ICS in comparison to LAMA, LABA/LAMA, or LABA/ICS have reported a lower rate of moderate or severe COPD exacerbations and reduced mortality in patients who were given triple therapy.8,9 These effects are most likely to be seen in patients with COPD who are:3,9

  • severely symptomatic
  • have moderate to very severe airflow obstruction
  • have a history of frequent and/or severe exacerbations.

3. Initiate and follow up non-pharmacological therapy

The 2020 GOLD report places a greater emphasis on the inclusion of non-pharmacological therapy in management than previous versions (see Figure 5).

At the time of diagnosis, management should include:3

  • reducing exposure to risk factors including smoking cessation
  • vaccination
  • guidance on self-management of breathlessness, energy conservation, and stress management
  • a written action plan
  • general advice on healthy living, including diet
  • advice that physical exercise is safe and encouraged for people with COPD.

Recommendations for the follow up of non-pharmacological treatments are based on the patient’s treatable traits, e.g. symptoms and exacerbations (see Figure 5). At follow-up reviews, management should include:3

  • checks of
    • inhaler technique
    • adherence to non-pharmacological as well as pharmacological therapy
    • smoking status and continued exposure to risk factors
  • encouragement of physical activity
  • referral for pulmonary rehabilitation considered
  • review of need for
    • oxygen therapy
    • ventilatory support
    • lung volume reduction
    • palliative approaches
  • update of the action plan.

Figure 5 Follow-up of non-pharmacological treatment

Figure 5: Follow-up of non-pharmacological treatment3

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

Patients with a high symptom burden and who are at risk of exacerbations (i.e. in GOLD groups B, C, and D) should be encouraged to take part in a formal pulmonary rehabilitation programme:3

  • traditional pulmonary rehabilitation with supervision remains the standard of care and first-line option
  • home-based exercise is an alternative for patients who are unable to attend pulmonary rehabilitation, but it appears to be less effective.10

4. Tailor education to the patient

Patient education does not itself change behaviour or even motivate patients, but it can play a role in improving skills, ability to cope with illness, and health status.3,11 Education for patients with COPD:3

  • should be combined with self-management support/coaching
  • can be delivered in individual and/or group education sessions
  • should adopt a motivational communication style when delivered one to one, to empower patients to take greater responsibility for their health and wellbeing.

Appropriate topics for an education programme include:3

  • smoking cessation
  • basic information about COPD
  • general approach to therapy
  • specific aspects of medical treatment (respiratory medications and inhalation devices)
  • strategies to help minimise breathlessness
  • advice about when to seek help
  • decision making during exacerbations
  • advance directives and end of life issues.

Clinicians need to offer strategies and techniques that are more collaborative than just didactic advice-giving if they are to help patients adopt sustainable self-management skills and become partners in their ongoing care.3 The self-management education plan should be personalised, taking into account the individual patient’s risk of exacerbations and their:

  • needs and preferences
  • personal goals.

5. Consider alternative causes for symptoms suggestive of an exacerbation

Approximately 50% of patients have had an exacerbation in the previous year, with around 25% having had more than one.12 Exacerbations have a negative impact on patients’ health status, rates of hospitalisation and readmission, and disease progression.3

The main symptoms of an exacerbation are increased breathlessness, cough, wheeze, and increased sputum purulence and volume.3

Differential diagnosis of COPD exacerbation

The symptoms of an exacerbation are quite non-specific and can also be caused by common co-morbidities such as cardiac disease. Clinical assessment to rule out differential diagnoses is recommended before making a diagnosis of a COPD exacerbation (see Figure 6).3

Figure 6 Differential diagnosis of COPD exacerbation

Figure 6: Differential diagnosis of COPD exacerbation3

COPD=chronic obstructive pulmonary disease

Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2020. Available at: goldcopd.org/gold-reports/

Reproduced with permission

Pharmacological treatments for exacerbations

The goals of treatment for COPD exacerbations are to minimise the negative impact of the current exacerbation and to prevent the development of subsequent events. Bronchodilator therapy can help to relieve breathlessness, but glucocorticoid and antibiotic therapy remain the mainstay of treatment to shorten the duration of the event and reduce the risk of relapse. There has been no major change in the use of these drugs for some years; however, new evidence has emerged about the effects of vitamin D supplementation and reducing the risk of exacerbations in patients with severe deficiency. 

Glucocorticoids

In exacerbations, systemic glucocorticoids:3

  • shorten recovery time and improve lung function and oxygenation
  • reduce the risk of early relapse and treatment failure
  • reduce the length of hospitalisation.

The 2020 GOLD report recommends a dose of 40 mg prednisolone per day for 5 days.3 Longer courses may be associated with an increased risk of pneumonia and mortality.3,13 Practitioners should, however, note that even short bursts of oral corticosteroids are associated with a short-term increased risk of sepsis and death, and although the absolute risk is low, corticosteroid use should be confined to patients with significant exacerbations.3,14

Antibiotics

Moderately or severely ill patients with COPD exacerbations and increased cough and sputum purulence should be treated with antibiotics:3

  • the duration of antibiotic therapy should be 5–7 days
  • when indicated, antibiotics can shorten recovery time and reduce the risk of early relapse treatment failure and length of hospitalisation
  • C-reactive protein and procalcitonin testing may help guide when antibiotic use is not necessary; however, rigorous confirmatory trials are required before recommending their use in routine clinical practice.

Vitamin D

The role of vitamin D in immune modulation has been implicated in the pathophysiology of exacerbations. As is the case with all chronic diseases, vitamin D levels are lower in people with COPD than they are in those with good health. A recent systematic review found that giving vitamin D supplements to people with severe deficiency resulted in a 50% reduction in moderate/severe COPD exacerbations and hospital admissions.3,15 GOLD recommends that all patients hospitalised for exacerbations should be assessed and investigated for severe deficiency (<10 ng/ml or <25 nM) and given vitamin D supplementation if required.3

Summary

The 2020 GOLD report consolidates previous recommendations on the diagnosis and assessment of COPD and its initial and subsequent pharmacological and non-pharmacological treatment. Although there have been no major revisions of previous recommendations, the 2020 report advocates a more holistic and comprehensive approach to the management of COPD, and is more up to date than the NICE guideline. this article highlights a few key aspects of COPD management from the 2020 report, but more information can be found in the GOLD pocket guide, and the GOLD app (goldcopd.org/download-app/) can help with the day-to-day management of patients with COPD.

Professor David Halpin

Consultant Physician and Honorary Professor of Respiratory Medicine, Exeter

Member of the GOLD Board of Directors and Science Committee

Implementation actions for STPs and ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.

  • Ensure that the 2020 GOLD report is circulated to all relevant clinicians, especially GPs and COPD specialist nurses in primary and secondary care
  • Update local formularies with the revised recommendations for inhaled therapies and that ensure triple agent inhalers (LABA/ICS/LAMA) are included
  • Consider autoconsultation proformas for use in primary care as prompts for required actions and tests on diagnosis and follow up
  • Commission responsive services for pulmonary rehabilitation and (with local public health departments) smoking cessation services
  • Recognise that people with COPD are at greater risk of mortality from COVID-19; ensure that these patients are kept updated with Public Health England advice.

STP=sustainability and transformation partnership; ICS=integrated care system; COPD=chronic obstructive pulmonary disease; LABA=long-acting beta2-agonist; ICS=inhaled corticosteroid; LAMA=long-acting muscarinic antagonist; COVID-19=coronavirus disease 2019.

Guidelines Learningcpd logo

After reading this article, ‘Test and reflect’ on your updated knowledge with our patient scenarios. We estimate that this activity will take you 30 minutes—worth 0.5 CPD credits.

References

1. British Lung Foundation. Chronic obstructive pulmonary disease (COPD) statistics. statistics.blf.org.uk/copd (accessed 30 January 2020).

2. NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline 115. NICE, 2018 (updated 2019). Available at: www.nice.org.uk/guidance/ng115

3. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2020 report. GOLD, 2019. Available at: goldcopd.org/gold-reports/

4. Global Initiative for Chronic Obstructive Lung Disease (GOLD).Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2017 report. GOLD, 2017. Available at: goldcopd.org/archived-reports/

5. Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease 2019 report. GOLD, 2018. Available at: goldcopd.org/archived-reports/

6. Jones P, Harding G, Berry P et al. Development and first validation of the COPD Assessment Test. Eur Respir J 2009; 34 (3): 648–654.

7. Fletcher C. Standardised questionnaire on respiratory symptoms: a statement prepared and approved by the MRC Committee on the Aetiology of Chronic Bronchitis (MRC breathlessness score). BMJ 1960; 2: 1662.

8. Lipson D, Barnhart F, Brealey N et al. Once-daily single-inhaler triple versus dual therapy in patients with COPD. N Engl J Med 2018; 378 (18): 1671–1680.

9. Vestbo J, Fabbri L, Papi A et al. Inhaled corticosteroid containing combinations and mortality in COPD. Eur Respir J 2018; 52 (6). doi: 10.1183/13993003.01230-2018.

10. Nolan C, Kaliaraju D, Jones S et al. Home versus outpatient pulmonary rehabilitation in COPD: a propensity-matched cohort study. Thorax 2019;74 (10): 996–998.

11. Spruit M, Singh S, Garvey C et al. An official American Thoracic Society/European Respiratory Society statement: key concepts and advances in pulmonary rehabilitation. Am J Respir Crit Care Med 2013; 188 (8): e13–64.

12. Raluy-Callado M, Lambrelli D, MacLachlan S, Khalid J. Epidemiology, severity, and treatment of chronic obstructive pulmonary disease in the United Kingdom by GOLD 2013. Int J Chron Obstruct Pulmon Dis 2015;10: 925–937.

13. Sivapalan P, Ingebrigtsen T, Rasmussen D et al. COPD exacerbations: the impact of long versus short courses of oral corticosteroids on mortality and pneumonia: nationwide data on 67 000 patients with COPD followed for 12 months. BMJ Open Respir Res 2019; 6 (1): e000407.

14. Waljee A, Rogers M, Lin P et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ 2017; 357: j1415.

15. Jolliffe D, Greenberg L, Hooper R et al. Vitamin D to prevent exacerbations of COPD: systematic review and meta-analysis of individual participant data from randomised controlled trials. Thorax 2019; 74 (4): 337–345.