GOLD Guideline-Based Treatment
The new classification should also help to identify the patient’s main needs: controlling symptoms, reducing future risks, or both. Based on the results of available randomized clinical trials, GOLD guideline developers suggest grouptailored strategies of management (Table 2, Figure 2).
Group A: Low Risk and Low Symptoms
The goal is to treat only as needed, using shortacting medications. No preference was given to the type of short-acting medication and the practitioner could select between short-acting beta agonists (SABAs) or short-acting anticholinergic (also known as short-acting antimuscarinic [SAMA]) medication as first-line therapy. Second-line therapy includes either the combination of both families of short-acting medications in 1 inhaler, or the use of 1 long-acting inhaler. As a rule of thumb, no patient in this group should be on more than 1 inhaler, and the combination of short and long-acting medications is not part of the recommendations. Patients in group A, and indeed everyone with COPD, benefit from respiratory immunizations and tobacco cessation.
Group B: Low Risk, High Symptoms
Again, the goal of treatment is symptom control. Based on the available evidence, this can be achieved using long-acting bronchodilators, without the need of inhaled corticosteroids (ICS). The first line of treatment should be just 1 bronchodilator, either a long-acting antimuscarinic (LAMA) or long-actingbeta agonist (LABA). These could be used together as second-line treatment (LAMA plus LABA), still without indication for ICS. It is important to remember that dyspnea, or other symptoms, could also be a manifestation of comorbid conditions, such as cardiovascular disease, obesity, deconditioning, and musculoskeletal diseases. 13 When spirometry is not used to confirm the diagnosis of COPD, patients may receive incremental types of inhalers instead of being evaluated for other causes of dyspnea, which might have led to more appropriate specific therapy. 14 As a result, judicious evaluation of the patient’s symptomsis recommended. The guidelines also recommend programs that increase physical activity for this group of patients, as well to those in groups C and D, as this can improve symptoms and decrease risk of exacerbations. 15
Group C: High Risk, Low Symptoms
The combination of ICS/LABA is the first-line therapy for this group, based on data showing the superiority of the ICS/LABA combination over monotherapy to reduce exacerbations and symptoms, as well as to improve QOL. 16,17 Monotherapy LABA is also a first-line GOLD recommendation. Selecting between ICS/LABA vs LABA should be individualized based on the reason that the patient was judged as high risk. In the authors’ practice, if
the risk is based only in spirometry values, using LABA as monotherapy is a good choice, while if the definition of high risk was based on the frequency of exacerbations, ICS/LABA is the first choice. The GOLD guidelines list the combination of LABA/LAMA as second-line therapy.
Group D: High Risk and High Symptoms
First-line therapy for this group is essentially the same that for group C, with similar considerations. The combination of LABA/LAMA is also recommended as second-line therapy, as well as the use of ICS/LABA and LAMA (all 3 major classes of controller medications together). It is worth noting that phosphodiesterase-4 inhibitors (PDE4-inh, roflumilast being the best known) can be considered as a third-line of therapy (in group C) or as part of secondline combinations (in group D).