Global Initiative for Chronic Obstructive Lung Disease (Updated 2014) (GOLD 2014)

102 Pages·1.598 MB·English

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Global Initiative for Chronic
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Obstructive
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GLOHBAL STRATEGY FOR THE DIAGNOSIS,
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MANAGEMENT, AND PREVENTION OF
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CHRONIC OBSTRUCTIVE PULMONARY DISEASE
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UPDATED 2014
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GLOBAL INITIATIVE FOR R
CHRONIC OBSTRUCTIVE LUNG DISEASE P
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GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND

PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARRY DISEASE
(UPDATED 2014)
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© 2014 Global Initiative for Chronic Obstructive Lung Disease, Inc.
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GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT,
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AND PREVENTION OF COPD (UPDATED 2014)
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GOLD BOARD OF DIRECTORS (2013) GOLD SCIENCE COMMITTEE* (2013) D
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Marc Decramer, MD, Chair Jørgen Vestbo, MD, Chair
Katholieke Universiteit Leuven Hvidovre University Hospital, Hvidovre, Denmark R
Leuven, Belgium and University of Manchester
Manchester, England, UK P
Jorgen Vestbo, MD, Vice Chair E
Odense University Hospital Alvar G. Agusti, MD
Odense C, Denmark (and) Thorax Institute, Hospital Clinic R
University of Manchester, Manchester, UK Univ. Barcelona, Ciberes, Barcelona, Spain

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Jean Bourbeau, MD Antonio Anzueto, MD
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McGill University Health Centre University of Texas Health Science Center
Montreal, Quebec, Canada San Antonio, Texas, USA
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Bartolome R. Celli, MD Marc Decramer, MD
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Brigham and Women’s Hospital Katholieke Universiteit Leuven
Boston, Massachusetts USA Leuven, Belgium T
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David S.C. Hui, MD Leonardo M. Fabbri, MD
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The Chinese University of Hong Kong University of Modena & Reggio Emilia
Hong Kong, ROC Modena, Ita ly
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M.Victorina López Varela, MD Paul JoOnes, MD
Universidad de la República St George’s Hospital Medical School
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Montevideo, Uruguay London, England, UK

Masaharu Nishimura, MD OFernando Martinez, MD
Hokkaido University School of Medicine University of Michigan School of Medicine
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Sapporo, Japan Ann Arbor, Michigan, USA

Roberto Rodriguez Roisin, MD - Nicolas Roche, MD

Hospital Clínic, University of Barcelona L Hôtel-Dieu
Barcelona, Spain A Paris, France
Robert A. Stockley, MD RI Roberto Rodriguez-Roisin, MD
University Hospitals Birmingham Thorax Institute, Hospital Clinic
Birmingham, UK E Univ. Barcelona, Barcelona, Spain
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Claus Vogelmeier, MD Donald Sin, MD
University of Gießen and Marburg A St. Paul’s Hospital
Marburg, Germany M Vancouver, Canada
Robert Stockley, MD
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University Hospital
GOLD SCIENCE DIRECTOR
Suzanne S. Hurd, PhD E Birmingham, UK
Vancouver, Washington, USA
T Claus Vogelmeier, MD
H University of Giessen and Marburg
Marburg, Germany
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Jadwiga A. Wedzicha, MD
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R Univ College London
London, UK
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P *Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org
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GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT,
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AND PREVENTION OF COPD (REVISED 2011)
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INVITED REVIEWERS David Price, MD D
University of Aberdeen
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Joan-Albert Barbera, MD Aberdeen, Scotland, UK
Hospital Clinic, Universitat de Barcelona
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Barcelona Spain Nicolas Roche, MD, PhD
University Paris Descartes P
A. Sonia Buist, MD Paris, France
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Oregon Health Sciences University
Portland, OR, USA Sanjay Sethi, MD R
State University of New York

Peter Calverley, MD Buffalo, NY, USA R
University Hospital Aintree
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Liverpool, England, UK GOLD NATIONAL LEADERS
(Submitting Comments)
Bart Celli, MD R
Brigham and Women’s Hospital Lorenzo Corbetta, MD
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Boston, MA, USA University of Florence
Florence, Italy T
M. W. Elliott, MD
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St. James’s University Hospital Alexandru Corlateanu, MD, PhD
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Leeds, England, UK State Medical and Pharmaceutical University
Republic of M oldova
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Yoshinosuke Fukuchi, MD
Juntendo University Le Thi TOuyet Lan, MD, PhD
Tokyo, Japan University of Pharmacy and Medicine
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Ho Chi Minh City, Vietnam
Masakazu Ichinose, MD
Wakayama Medical University OFernando Lundgren, MD
Kimiidera, Wakayama, Japan Pernambuco, Brazil
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Christine Jenkins, MD E. M. Irusen, MD
Woolcock Institute of Medical Research - University of Stellenbosch

Camperdown. NSW, Australia L South Africa
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H. A. M. Kerstjens, MD Timothy J. MacDonald, MD
University of Groningen RI St. Vincent’s University Hospital
Groningen, The Netherlands Dublin, Ireland
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Peter Lange, MD T Takahide Nagase, MD
Hvidovre University Hospital University of Tokyo
Copenhagen, Denmark A Tokyo, Japan
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M.Victorina López Varela, MD Ewa Nizankowska-Mogilnicka, MD, PhD
Universidad de la República Jagiellonian University Medical College
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Montevideo, Uruguay Krakow, Poland
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Maria Montes de Oca, MD Magvannorov Oyunchimeg, MD
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Hospital Universitario de Caracas Ulannbatar, Mongolia
Caracas, Venezuela H
Mostafizur Rahman, MD
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Atsushi Nagai, MD NIDCH
Tokyo Women’s Medical UIniversity Mohakhali, Dhaka, Bangladesh
Tokyo, Japan R
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Dennis Niewoehner, MD
Veterans Affairs MPedical Center
Minneapolis, MN, USA
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PREFACE
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In 2011, the Global Initiative for Chronic Obstructive Lung We are most appreciative of the unrestrRicted educational
Disease (GOLD) released a consensus report, Global grants from Almirall, AstraZeneca, BoPehringer-Ingelheim,
Strategy for the Diagnosis, Management, and Prevention of Chiesi, Forest Laboratories, GlaxoESmithKline, Merck
COPD. It recommended a major revision in the management Sharp & Dohme, Mylan, Nonin Medical, Novartis, Pearl
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strategy for COPD that was presented in the original 2001 Therapeutics, Pfizer, Quintiles, and Takeda that enabled

document. Updated reports released in January 2013 and development of this report.R
January 2014 are based on scientific literature published O
since the completion of the 2011 document but maintain

the same treatment paradigm. Assessment of COPD is R
based on the patient’s level of symptoms, future risk of E
exacerbations, the severity of the spirometric abnormality, T
and the identification of comorbidities. Marc DecramLer, MD
Chair, GOLAD Board of Directors
The GOLD report is presented as a “strategy document” Professor of Medicine

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for health care professionals to use as a tool to implement Chief of the Respiratory Division
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effective management programs based on available health University Hospital
care systems. The quadrant management strategy tool is KaNtholieke Universiteit, Leuven Belgium
designed to be used in any clinical setting; it draws together
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a measure of the impact of the patient’s symptoms and an
assessment of the patient’s risk of having a serious adversDe
health event in the future. More and more evidence is b eing
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produced to evaluate this strategy*. Evidence will con tinue
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to be evaluated by the GOLD committees and management
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strategy recommendations modified as required.
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GOLD has been fortunate to have a network of Jørgen Vestbo, MD
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international distinguished health professionals from Vice-Chair, GOLD Board of Directors
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multiple disciplines. Many of these experts have initiated Chair, GOLD Science Committee
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investigations of the causes and prevalence of COPD in Professor of Respiratory Medicine
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their countries, and have developed innovative approaches Odense University Hospital
for the dissemination and implem entation of the GOLD Odense, Denmark (and)
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management strategy. The GOLD initiative will continue The University of Manchester
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to work with National Leaders and other interested health Manchester Academic Health Science
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care professionals to bring COPD to the attention of University Hospital of South Manchester
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governments, public health officials, health care workers, NHS Foundation Trust, Manchester, UK
and the general publiGc to raise awareness of the burden
of COPD and to deIvelop programs for early detection,
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prevention and approaches to management. *Lange P, Marott JL, Vestbo J, Olsen KR, Ingebrigtsen TS, Dahl M,
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Nordestgaard BG. Prediction of the clinical course of chronic obstructive
P pulmonary disease, using the new GOLD classification: a study of the general
O population. Am J Respir Crit Care Med. 2012 Nov 15;186(10):975-81.
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TABLE OF CONTENTS
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Preface.............................................................. .iv 3. Therapeutic Options 19
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Methodology and Summary of New Key Points 20
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Recommendations viii Smoking Cessation 20
Introduction.....................................................xiv Pharmacotherapies for SmokingR Cessation 20
Pharmacologic Therapy for StableP COPD 21
1. Definition and Overview 1
Overview of the MedicationEs 21
Key Points 2
Definition 2 Bronchodilators R 21
Corticosteroids 24
Burden Of COPD 2
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Phosphodiesterase-4 Inhibitors 25
Prevalence 3
Morbidity 3 Other PharmacoOlogic Treatments 25
Mortality 3 Non-PharmacologicR Therapies 26
Economic Burden 3 Rehabilitation 26
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Components of Pulmonary Rehabilitation
Social Burden 4
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Factors That Influence Disease Programs 27
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Development And Progression 4 Other Treatments 28
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Genes 4 Oxygen Therapy 28

Age and Gender 4 VenTtilatory Support 29
Lung Growth and Development 4 SOurgical Treatments 29
Exposure to Particles 5 NPalliative Care, End-of-life Care, Hospice Care 29
Socioeconomic Status 5
Asthma/Bronchial Hyperreactivity 5 O4. Management of Stable COPD 31
Chronic Bronchitis 5D Key Points 32
Infections 5 Introduction 32
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Pathology, Pathogenesis And Pathophysiology 6 Identify And Reduce Exposure to Risk Factors 33
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Pathology 6 Tobacco Smoke 33
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Pathogenesis 6 Occupational Exposures 33
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Pathophysiology R 6 Indoor And Outdoor Pollution 33
E Treatment of Stable COPD 33
2. Diagnosis and Assessment T 9 Moving from Clinical Trials to Recommendations
Key Points A 10 for Routine Practice Considerations 33
Diagnosis M 10 Non-Pharmacologic Treatment 34
Symptoms 11 Smoking Cessation 34

Medical History D 12 Physical Activity 34
Physical Examination E 12 Rehabilitation 34
Spirometry T 12 Vaccination 34
Assessment Of DiseaHse 12 Pharmacologic Treatment 35
Assessment of SGymptoms 13 Bronchodilators - Recommendations 35
Choice of Cut Points 13 Corticosteroids and Phosphodiesterase-4
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Spirometric ARssessment 14 Inhibitors - Recommendations 37
AssessmeYnt of Exacerbation Risk 14 Monitoring And Follow-Up 37
AssessPment of Comorbidities 15 Monitor Disease Progression and
CombOined COPD Assessment 15 Development of Complications 37
Additional Investigations 16 Monitor Pharmacotherapy and
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Differential Diagnosis 17 Other Medical Treatment 37
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Monitor Exacerbation History 37 Tables
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Monitor Comorbidities 37 Table A. Description of Levels of Evidence xvi
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Surgery in the COPD Patient 38 Table 2.1. Key Indicators for Considering
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a Diagnosis of COPD 10
5. Management of Exacerbations 39 Table 2.2. Causes of Chronic Cough O 11
Key Points 40 Table 2.3. Considerations in PerformRing
Definition 40 Spirometry P 12
Diagnosis 40 Table 2.4. Modified Medical Research Council
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Assessment 41 Questionnaire for Assessing the Severity of
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Breathlessness 13
Treatment Options 41
Table 2.5. Classification o f Severity of Airflow
Treatment Setting 41 R
Limitation in COPD (Based on Post-Bronchodilator
Pharmacologic Treatment 41 O
FEV ) 14
Respiratory Support 43 Table 2.16. RISK IN COPD: Placebo-limb data from
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Hospital Discharge and Follow-up 44
TORCH, Uplift, and Eclipse 15
Home Management of Exacerbations 45 E
Table 2.7. COPD and its Differential Diagnoses 18
Prevention of COPD Exacerbations 45 T
Table 3.1. Treating Tobacco Use and Dependence:
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A Clinical Practice Guideline—Major Findings and
6. COPD and Comorbidities 47 A
Recommendations 20
Key Points 48
Table 3T.2. Brief Strategies to Help the Patient Willing
Introduction 48 toO Quit 21
Cardiovascular Disease 48 TaNble 3.3. Formulations and Typical Doses of COPD
Osteoporosis 49 Medications 22

Anxiety and Depression 50 OTable 3.4. Bronchodilators in Stable COPD 23
Lung Cancer 50D Table 3.5. Benefits of Pulmonary Rehabilitation in
Infections 50 COPD 26
Metabolic Syndrome and Diabetes -50 Table 4.1. Goals for Treatment of Stable COPD 32
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Bronchiectasis 50 Table 4.2. Model of Symptom/Risk of Evaluation of
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COPD 33
7. Asthma & COPD Overlap Syndrome (RAICOS) 51 Table 4.3. Non-pharmacologic Management
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References 53 Table 4.4. Initial Pharmacologic Management
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A of COPD 36
Figures Table 5.1. Assessment of COPD Exacerbations:
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Figure 1.1. Mechanisms Underlying Airflow Limitation
Medical History 41
in COPD D 2 Table 5.2. Assessment of COPD Exacerbations:
Figure 2.1A. Spirometry - Normal Trace 13 Signs of Severity 41
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Figure 2.1B. Spirometry - Obstructive Disease 13 Table 5.3. Potential Indications for Hospital
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Figure 2.2. Relationship Between Health-Related Assessment or Admission 41
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Quality of Life, Post-Bronchodilator FEV and
Table 5.4. Management of Severe but Not
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GOLD SpirometGric Classification 14 Life-Threatening Exacerbations 42
Figure 2.3. AssocIiation Between Symptoms, Table 5.5. Therapeutic Components of Hospital
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Spirometric Classification and Future Risk of
Management 42
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Exacerbations 15
Table 5.6. Indications for ICU Admission 43
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Table 5.7. Indications for Noninvasive Mechanical
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Ventilation 43
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Table 5.8. Indications for Invasive Mechanical
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Ventilation 43
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Table 5.9. Discharge Criteria 44
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Table 5.10. Checklist of items to assess at time of
Discharge from Hospital 44 O
Table 5.11. Items to Assess at Follow-Up Visit 4-6 R
Weeks After Discharge from Hospital 44 P
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METHODOLOGY AND SUMMARY OF NEW RECOMMENDATIONS GLOCBAL
STRATEGY FOR DIAGNOSIS, MANAGEMENT AND PREVENTION OF UCOPD
2014 UPDATE1 D
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When the Global Initiative for Chronic Obstructive review by the Committee during the ATS meeting.
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Lung Disease (GOLD) program was initiated in The second search included publications for April 1
1998, a goal was to produce recommendations for – August 31 for review by the ComPmittee during the
management of COPD based on the best scientific ERS meeting. The third searchE for publications from
information available. The first report, Global Strategy September – December were reviewed in December
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for Diagnosis, Management and Prevention of COPD by the GOLD Board of Directors. Publications in

was issued in 2001. In 2006 and again in 2011 a peer review journals not cRaptured by Pub Med can be
complete revision was prepared based on published submitted to the Chair,O GOLD Science Committee,
research. These reports, and their companion providing an abstract and the full paper are submitted

documents, have been widely distributed and in (or translated intoR) English.
translated into many languages and can be found on E
the GOLD website (www.goldcopd.org). Members of the Committee receive a summary of
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citations and all abstracts. Each abstract is assigned
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The GOLD Science Committee2 was established to two Committee members, although all members
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in 2002 to review published research on COPD are offered the opportunity to provide an opinion

management and prevention, to evaluate the impact on anyT abstract. Members evaluate the abstract
of this research on recommendations in the GOLD or, upO to her/his judgment, the full publication, by
documents related to management and prevention, answering four specific written questions from a short
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and to post yearly updates on the GOLD website. Its questionnaire, and to indicate if the scientific data

members are recognized leaders in COPD research Opresented impacts on recommendations in the GOLD
and clinical practice with the scientific credentials to report. If so, the member is asked to specifically
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contribute to the task of the Committee and are invited identify modifications that should be made.

to serve in a voluntary capacity. -

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The first update of the 2011 revised report waAs to discuss each publication that was considered by
released in January 2013. This second updIate, at least 1 member of the Committee to potentially
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released January 2014, is based on the impact of have an impact on the COPD management.
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publications from January 1 through December 31, The full Committee then reaches a consensus
2013. Posted on the website along wTith the updated on whether to include it in the report, either as a
documents is a list of all the publicaAtions reviewed by reference supporting current recommendations, or
the Committee. M to change the report. In the absence of consensus,
disagreements are decided by an open vote of the

Process: To produce the upDdated documents a full Committee. The final review and approval of all
Pub Med search is compleEted using search fields recommendations is provided by the GOLD Board of
established by the Committee: 1) COPD, All Fields, Directors at its annual meeting in December.
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All Adult: 19+ years, only items with abstracts, Clinical
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Trial, Systematic Reviews, Human. The first search Recommendations by the GOLD Committees for use
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included publications for January 1 – March 31 for of any medication are based on the best evidence
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1 The Global Strategy for Diagnosis, Management and Prevention of COPD (updated 2014), labeling directives from government regulators. The
the Pocket Guide (updYated 2014) and the complete list of references examined by the
Committee does not make recommendations for
Committee are available on the GOLD website www.goldcopd.org.
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2 Members (2012-2013): J. Vestbo, Chair; A. Agusti, A. Anzueto, L. Fabbri, P. Jones, F. therapies that have not been approved by at least one
Martinez, N. RoOche, R. Rodriguez-Roisin, D. Sin, R. Stockley, C. Volgelmeier, W. Wedzicha. regulatory agency.
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As an example of the workload of the Committee, for twice-daily aclidinium bromide in COPD patients: the
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the 2014 update, between January and December, ATTAIN study. Eur Respir J 2012 Oct;40(4):830-6.
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2013, 292 articles met the search criteria. Of the Reference 558: Kerwin E, Hébert J, Gallagher N,
292 papers, 30 were identified to have an impact on Martin C, Overend T, Alagappan VK, Lu YD, Banerji D.
the GOLD report posted on the website in January Efficacy and safety of NVA237 versus Oplacebo and
2014 either by: A) modifying, that is, changing tiotropium in
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the text or introducing a concept requiring a new patients with COPD: the GLOW2 study. Eur Respir J
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recommendation to the report; B) confirming, that 2012 Nov;40(5):1106-14.
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is, adding or replacing an existing reference; or C)
requiring modification for clarification of the text. Page 24, left column, first paRragraph, replace
section beginning with “Tio tropium delivered…” to
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SUMMARY OF RECOMMENDATIONS IN THE 2014 end of paragraph with: Tiotropium delivered via the
UPDATE Respimat® soft mist inhOaler was associated with a
significantly increase d risk of mortality compared
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A. Additions to the text with placebo in a meta-analysis519; however, the
findings of the TIEOSPIR® trial showed that there was
Page 17, left column, last paragraph line 5, insert no difference iTn mortality or rates of exacerbation
statement and reference: Exercise capacity may fall when compaLring tiotropium in a dry-powder inhaler
in the year before death557. to the ResApimat® inhaler559. Use of solutions with
Reference 557: Polkey MI, Spruit MA, Edwards LD, a facem ask has been reported to precipitate acute
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Watkins ML, Pinto-Plata V, Vestbo J, et al; Evaluation glaucoma, probably by a direct effect of the solution
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of COPD Longitudinally to Identify Predictive on the eye.
Surrogate Endpoints (ECLIPSE) Study Investigators. ReNference 559: Wise RA, Anzueto A, Cotton D,
Six-minute-walk test in chronic obstructive pulmonary Dahl R, Devins T, Disse B, et al for the TIOSPIR
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disease: minimal clinically important difference for Investigators. Tiotripium Respimat Inhaler and the
death or hospitalization. Am J Respir Crit Care Med D Risk of Death in COPD. N Engl J Med 2013 Oct
2013 Feb 15;187(4):382-6. 17;369(16):1491-1501.
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Page 23, right column, second paragraph, replace Page 24, right column, end of second paragraph,
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sentence on line 13 beginning with “Tiotropium has…” insert statement and references: Combinations
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with: Among long-acting anticholinergics, Racclidinium of a long-acting beta -agonist and a long-acting
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has a duration of at least 12 hours552 whereas anticholinergic have shown a significant increase in
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tiotropium and glycopyrronium have a duration of lung function whereas the impact on patient reported
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action of more than 24 hours209-211. outcomes is still limited560. There is still too little
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Reference 552: Jones PW, Singh D, Bateman ED, evidence to determine if a combination of long-acting
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Agusti A, Lamarca R, de Miquel G,Segarra R, Caracta bronchodilators is more effective than a long-acting
C, Garcia Gil E. Efficacy and s afety of twice-daily anticholinergic alone for preventing exacerbations561.
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aclidinium bromide in COPD patients: the ATTAIN Reference 560: Bateman ED, Ferguson GT,
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study. Eur Respir J 2012 Oct;40(4):830-6. Barnes N, Gallagher N, Green Y, Henley M, Banerji
T D. Dual bronchodilation with QVA149 versus single
Page 23, right columnH, second paragraph, insert bronchodilator therapy: the SHINE study. Eur Respir
statement and referGence at the end: The long-acting J 2013 Dec;42(6):1484-94.
anticholinergics aclidinium and glycopyrronium Reference 561: Wedzicha JA, Decramer M, Ficker
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seem to have siRmilar action on lung function and JH, Niewoehner DE, SandstroÅNm T, Taylor AF, et
breathlessnesYs as tiotropium, whereas far less data al. Analysis of chronic obstructive pulmonary disease
are available for other outcomes552, 558. exacerbations with the dual bronchodilator QVA149
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Reference 552: Jones PW, Singh D, Bateman compared with glycopyrronium and tiotropium
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ED, Agusti A, Lamarca R, de Miquel G, Segarra (SPARK): a randomised, double-blind, parallel-group
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R, Caracta C, Garcia Gil E. Efficacy and safety of study. Lancet Respir Med 2013;1:199–209
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