New GOLD Guideline 2011

7/27/2019 New GOLD Guideline 2011

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GOLD Guideline 2011:Global Strategy for

Diagnosis, Management, and

Prevention ofCOPD

LULUK ADIPRATIKTO


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The GOLD document

Chapter 1. Definition and overview

Chapter 2. Diagnosis & assessment

Chapter 3. Therapeutic options

Chapter 4. Manage stable COPD

Chapter 5. Manage exacerbations

Chapter 6. COPD comorbidities


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Definition of COPD

COPD: a common preventable and treatabledisease, is characterized by persistent airflowlimitation that is usually progressive and

associated with an enhanced chronicinflammatory response in the airways and thelung to noxious particles or gases.

Exacerbations and comorbidities contributeto the overall severity in individual patients.

Source: GOLD guideline 2011 Update


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Prevention of COPDPrimary and Secondary

A number of risk factors for COPD have been

identified several of these enable primary

prevention of COPD; e.g., smoking, indoor air

pollution and poorly managed asthma.

Smoking cessation is the single most important

intervention in the smoking COPD patient

As COPD is the result of cumulative harmfulexposures, other exposures to dust, fumes and

smoke should be reduced whenever possible



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Diagnosis of COPD

A clinical diagnosis of COPD should be considered

in any patient who has dyspnea, chronic cough or

sputum production, and/or a history of exposure

to risk factors for the disease.

Spirometry is requiredto make the diagnosis in

this clinical context; the presence of a post-

bronchodilator FEV1/FVC


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Assessment of COPD

1. Assess symptoms

2. Assess degree of airflow limitation using spirometry

3. Assess risk of exacerbations

4. Assess comorbidities



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Assessment of COPD

1. Assess symptoms




Use the COPD Assessment Test (CAT),

or the mMRC Breathlessness scale

Notes: The CAT score is preferred since it provides a more comprehensive

assessment of the symptomatic impact of the disease.



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mMRC Dyspnoe scale

(modified Medical Research Council)

Tingkat1 Tidak terganggu oleh sesak napas kecualisaat olah-raga berat.

Tingkat

2Terganggu dengan sesak napas ketika

terburu-buru berjalan di tanah yang datar

atau mendaki tanjakan.

Tingkat

3

Berjalan lebih lambat pada permukaan

yang datar dibandingkan orang seusia

karena sesak napas atau harus berhenti

untuk bernapas ketika berjalan pada

kecepatan sendiri di permukaan yang

datar.

Tingkat

4Berhenti untuk bernapas setelah berjalan

90 meter atau setelah beberapa menit di

permukaan yang datar

Tingkat

5Terlalu sesak untuk meninggalkan rumah

atau sesak saat berpakaian atau berganti

pakaian.


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Assessment of COPD

1. Assess symptoms




Use spirometry for grading severity according

to spirometry, using four grades split at 80%,

50% and 30% of predicted value


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Assessment of COPD

1. Assess symptoms



4. Assess comorbiditiesUse history of exacerbations & spirometry.

Two exacerbations or more within the last year

or an FEV1 < 50% of predicted value are

indicators of high risk



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Combined assessment of COPD

1. Assess symptoms



An opportunity to combine these assessments for

the purpose of improving management of COPD


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RISK

(GOLDC

las

sificationof

AirflowLi

mitation)

4

(C) (D)2 or

more

RIS

K

(Exacerbationhistory)

3

2

(A) (B)

1

1 0

mMRC 0-1 mMRC 2+

CAT


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Combined

assessment

of COPD

Patient CharacteristicSpirometric

classification

Exacerbation

per yearmMRC CAT

A Low risk, less symptoms GOLD 1-2 1 0-1 < 10

B Low risk, more symptoms GOLD 1-2 1 2+ 10

C High risk, less symptoms GOLD 3-4 2+ 0-1 < 10

D High risk, more symptoms GOLD 3-4 2+ 2+ 10

R

ISK

(GOLDC

lassificationof

Airflow

Limitation) 4

(C) (D)2 or

more

RISK

(Exacerb

ationh

istory)

3

2

(A) (B)

1

1 0

mMRC 0-1 mMRC 2+

CAT


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Management of COPDPharmacological First choice

GOLD 4

ICS + LABA or ICS + LABA or 2 ormore

GOLD 3

ICS + LAMA ICS + LAMA

GOLD 2

SABA or SAMA prn LABA or LAMA

1

GOLD 1 0

mMRC 0-1 mMRC 2+

CAT


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I: Mild II: Moderate III: Severe IV: Very Severe

FEV1 80% pred FEV1


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Management of COPDPharmacological First alternatives

GOLD 4

LABA

ICS and LAMA

ICS/LABA and LAMA

ICS/LABA and PDE4-inh

LAMA and LABA

LAMA and PDE 4-inh

2 or

more

GOLD 3

and LAMA

GOLD 2LABA or

LAMA or

SABA and SAMALABA and LAMA

1

GOLD 1 0

mMRC 0-1 mMRC 2+

CAT


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Management of COPD the aims

Relieve symptoms

Improve exercise tolerance

Improve health status

Prevent disease progression

Prevent and treat exacerbations

Reduce mortality

Reduce

symptoms

Reduce

risk



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Management of COPDPharmacological

Patient First choice First alternatives Other alternatives

A SABA or SAMA prnLABA or LAMA or

SABA and SAMATheophylline

B LABA or LAMA LABA and LAMA SABA and/or SAMATheophylline

C ICS + LABA or LAMA LABA and LAMA

PDE4-inh

SABA and/or SAMA

Theophylline

D ICS + LABA or LAMA

ICS & LAMA or

ICS+LABA and LAMA or

ICS+LABA & PDE4-inh or

LABA and LAMA or

LAMA and PDE4-inh

Carbocysteine

SABA and/or SAMA

Theophylline



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Management of COPDNon-pharmacological

Patient Essential RecommendedDepending on local

guidelines

ASmoking cessation (can include

pharmacological treatment)Physical activity

Flu vaccination

Pneumococcal

vaccination

B - D

Smoking cessation (can include

pharmacological treatment)

Pulmonary rehabilitation

Physical activity

Flu vaccination

Pneumococcal

vaccination



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Bronchodilators - Recommendations

For both 2-agonists and anticholinergics, long-actingformulations are preferred over short-acting formulations(Evidence A).

The combined use of SABA or LABA and anticholinergics

may be considered if symptoms are not improved withsingle agents (Evidence B).

Based on efficacy and side effects inhaled bronchodilatorsare preferred over oral bronchodilators (Evidence A).

Based on evidence of relatively low efficacy and more sideeffects, treatment with theophylline is not recommendedunless other long-term treatment bronchodilators areunavailable or unaffordable (Evidence B).



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Steroid & PDE4 inhibitors - Recommendations

There is no evidence to recommend a short-term therapeutic trial withoral steroids in patients with COPD to identify those who will respond toICS or other medications.

Long-term treatment with ICS is recommended for patients with severeand very severe COPD and frequent exacerbations that are not adequatelycontrolled by long-acting bronchodilators (Evidence A).

Long-term monotherapy with oral corticosteroid is not recommended inCOPD (Evidence A).

Long-term monotherapy with ICS is not recommended in COPD because itis less effective than combination of ICS with LABA (Evidence A).

The PDE4 inh may also be used to reduce exacerbations for patients withchronic bronchitis, severe and very severe COPD, and frequentexacerbations that are not adequately controlled by long-actingbronchodilators (Evidence B).



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COPD and co-morbidities

COPD patients are at increased risk for: Cardiovascular diseases a major comorbidity in COPD and probably

both the most frequent & most important disease coexisting with COPD

OsteoporosisOsteoporosis & depression are also major comorbidities inCOPD & are often under-diagnosed & associated with poor QoL & prognosis

Respiratory infections

Anxiety and Depression

Diabetes

Lung cancer frequently seen in patients with COPD and has been found to bethe most frequent cause of death in patients with mild COPD

These co-morbid conditions may influence mortality and hospitalizations and

should be looked for routinely, and treated appropriately (as if the patient did

not have COPD).


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2011 GOLD revision Conclusions I

Spirometry is requiredto make the diagnosis ofCOPD in clinical context; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the

presence of persistent airflow limitation and thusof COPD.

Prevention of COPD is to a large extent possibleand should have high priority

Assessment of COPD requires assessment ofSymptoms, Degree of airflow limitation, Risk ofexacerbation, and Comorbidities



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2011 GOLD revision Conclusions II

The combined assessment of symptoms and risk

of exacerbations is the basis for management of

COPD, both non-pharmacological and

pharmacological

The beneficial effects of pulmonary rehabilitation

as well as physical activity cannot be overstated

Comorbidities should be looked for and ifpresent treated to the same extents as if the

patient did not have COPD.


Documents

New GOLD Guideline 2011