The Allergist’s Guide to the GOLD Guidelines for COPD

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death in the United States, and the condition costs the country about $50 billion annually. Allergy/immunology as a specialty is encountering diagnosed and undiagnosed COPD patients at an increased rate, according to a session at the annual ACAAI meeting, so specialists are in a unique position to be at the forefront of COPD care.

To help specialists better understand evaluation, staging, grading, and treatment in COPD, Mario Castro, MD, MPH, of the Washington University School of Medicine in St. Louis, reviewed the recently revised recommendations from the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

For evaluation, Castro emphasized that testing for alpha 1 antitrypsin deficiency is recommended for all patients with suspected COPD. He also reviewed the importance of a basic chemistry panel, full pulmonary function testing, pulse oximetry at rest and with exertion, and possibly computed tomography for candidates for lung cancer screening.

The GOLD recommendations offer straightforward steps, Castro said.

• step 1: spirometry
• step 2: symptom evaluation using perhaps some of the following:
  • COPD Assessment Test, which he uses the most
  • Chronic Respiratory Questionnaire
  • George’s Respiratory Questionnaire
  • Modified Medical Research Council questionnaire
• step 3: exacerbation risk assessment using spirometry and history
  • Two or more exacerbations within the past year or an FEV1 < 50% of predicted value are indicators of high risk for exacerbations
  • One or more hospitalizations for a COPD exacerbations places a patient in the high-risk category
  • Blood eosinophil count may also predict exacerbation rates.

Castro urged the audience to use the 2018 GOLD algorithm for assessing the clinical severity of COPD. The algorithm is availabile on slide 39 of the GOLD Teaching Slide Set at https://goldcopd.org/gold-teaching-slide-set/.

Regarding treatment contitions, Castro highlighted that only smoking cessation has been shown reduce mortality in COPD, and it also has been shown to slow lung function decline.

“Smoking cessation has the greatest capacity to influence the natural history of COPD. Providers should encourage all patients who smoke to quit,” he said, outlining five A’s that healthcare practitioners can apply to help patients who are willing to quit: ask, advise, assess, assist, and arrange. Long-term smoking abstinence rates are best when plans combine pharmacotherapy and nicotine replacement.

Other key nonpharmacologic approaches to treatment of patients with COPD are patient education, vaccinations (particularly influenza and pneumococcal in patients older than 65), pulmonary rehabilitation, oxygen therapy, and surgical and non-surgical alternatives. Additionally, he said, all COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active. Castra said these options are essential, but often ignored in primary care practices.

Although appropriate pharmacologic therapy can reduce COPD symptoms, reduce frequency and severity of exacerbations, and improve health status and exercise tolerance, Castro said, none has been shown to conclusively modify long-term decline in lung function. He referred attendees to the 2018 GOLD recommendations for initial pharmacological management of COPD, described in detail at https://goldcopd.org/gold-teaching-slide-set/.