Early stage COPD carries a significant healthcare burden that is currently underrecognised, underdiagnosed and undertreated. Furthermore, patients at this stage can rapidly decline to advanced disease, especially if they continue to smoke. The natural history of the disease in early stages remains largely unknown, but emerging evidence indicates that specialists are able to reduce lung function decline and exacerbations, and improve quality of life, in early stage COPD, mainly through smoking cessation.
Evidence from randomised clinical trials also suggests a growing impact of pharmacotherapy on clinical outcomes in early disease. This newer evidence led the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines group to update their treatment guidelines late last year.
“Guidelines needed to be updated to reflect this greater understanding of early stage disease, and trials need to be conducted to definitively show the benefits of intensive treatment so that we can meet the large, unmet clinical needs of this important patient group,” according to Dr Jørgen Vestbo, Chair of the GOLD Science Committee, which combed through recent scientific literature on COPD and prepared the new, extensively revised version of its report, “Global strategy for diagnosis, management, and prevention of COPD.” The revised report introduces a more individualised approach to COPD classification and, based on this, a new paradigm for management of stable disease.
Past versions of the GOLD report classified COPD based exclusively on lung function as measured by spirometry, with stages designated mild through very severe.
“Spirometry is essential for diagnosis of COPD, but it doesn’t fully capture the impact of the disease on individual patients,” said Dr Vestbo. “For example, some patients might have severe breathlessness despite relatively well preserved lung function, while other patients are much more prone to acute exacerbations.”
Therefore, the new report recommends that doctors assess COPD using a combination of a patient’s spirometry results, severity of symptoms, and history of exacerbations.
Based on this combined assessment, the GOLD report divides patients into four groups: A (less symptoms, low risk of exacerbations and other negative events); B (more symptoms, low risk); C (less symptoms, high risk); and D (more symptoms, high risk). The report also provides specific treatment recommendations for each of these groups.
“At first, this system for COPD assessment may seem more complex because it has more steps,” acknowledged Dr Vestbo. “However, we believe that this approach more accurately reflects the experience of individual COPD patients, so it will help doctors find the best treatment for their patients more quickly.”
Regular treatment of COPD can help prevent exacerbations. However, studies show that up to half of people with the disease do not know they have it.
“People who have symptoms of COPD and have been exposed to risk factors such as tobacco smoking or smoke from indoor cooking and heating fires should ask their doctor about having a spirometry test,” said Dr Vestbo.
The new GOLD report incorporates information and recommendations about emerging therapies for COPD, such as phosphodiesterase-4 inhibitors.
The report also emphasises that spirometry is necessary for diagnosis of COPD in primary care.
“Diagnosis of COPD in primary care is complex, as many clinical symptoms are similar to asthma and heart disease, which may lead to misdiagnosis and suboptimal disease management,” the report states. “Spirometry is the best method for diagnosing COPD and distinguishing between COPD, asthma, and cardiovascular diseases. Airway obstruction is fully reversible in asthma, but not in COPD, and can be confirmed when the postbronchodilator ratio of forced expiratory volume in one second (FEV1) to forced vital capacity (FVC) is <0.7.”
Dr Vestbo said that knowledge of COPD treatment guidelines and a “proactive attitude toward disease management” by GPs are key to improving symptom control and patients’ quality of life.
“Identification of the appropriate drug/inhaler combination, patient education, training on inhaler use followed by regular monitoring, and pulmonary rehabilitation are also vital to successful COPD management. The GOLD guidelines outline steps to aid physicians in devising and implementing an optimal management plan for COPD patients.”
Although most COPD cases can be managed in primary care, referral to a pulmonary specialist should be considered if the diagnosis is unclear, the patient is younger than 40 years of age, does not respond to treatment, has an accelerated decline in lung function, suffers from frequent exacerbations despite treatment, and/or the patient needs to be evaluated for surgery, the updated guidelines state.
The Global Strategy for Diagnosis, Management, and Prevention of COPD was first published in 2001. The new version, which is the first major revision of the document since 2006, builds on the strengths from the original recommendations and incorporates new knowledge.
“The new management approach can be used in any clinical setting anywhere in the world and moves COPD treatment towards individualised medicine –matching the patient’s therapy more closely to his or her needs,” Dr Vestbo said.
The World Health Organisation estimates an increase of greater than 30 per cent in the mortality rate for COPD over the next decade and predicts that it will become the third leading cause of death by 2030. Once more common in men, more women than men in the US now die each year of COPD. The increasing rate of COPD in women is mainly due to a change in smoking habits of this group, research has shown.
