Global Initiative for Chronic Obstructive L ung D isease REPRODUCE OR GOLD Report 2015 ALTER NOT MATERIAL-DO COPYRIGHTED GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE UPDATED 2016 Visit the GOLD website at www.goldcopd.org © 2016 Global Initiative for Chronic Obstructive Lung Disease GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (UPDATED 2016) REPRODUCE OR ALTER NOT MATERIAL-DO COPYRIGHTED © 2016 Global Initiative for Chronic Obstructive Lung Disease, Inc. i GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (UPDATED 2016) GOLD BOARD OF DIRECTORS (2015) GOLD SCIENCE COMMITTEE* (2015) Marc Decramer, MD, Chair Claus Vogelmeier, MD University of Leuven University of Giessen and Marburg Leuven, Belgium Marburg, Germany Alvar G. Agusti, MD Alvar G. Agusti, MD Hospital Clínic, Universitat de Barcelona Thorax Institute, Hospital Clinic Barcelona Spain Univ. Barcelona, Ciberes, Barcelona, Spain Jean Bourbeau, MD Antonio Anzueto, MD McGill University Health Centre University of Texas Health Science Center Montreal, Quebec, Canada San Antonio, Texas, USA Bartolome R. Celli, MD Marc Decramer, MD Brigham and Women’s Hospital Katholieke Universiteit Leuven Boston, Massachusetts USA Leuven, Belgium Rongchang Chen, MD Leonardo M. Fabbri, MD Guangzhou Institute of Respiratory Disease University of Modena & Reggio Emilia Guangzhou, PRC Modena, Italy REPRODUCE Gerard Criner, MD Fernando Martinez,OR MD Temple University School of Medicine University of Michigan School of Medicine Philadelphia, Pennsylvania USA Ann Arbor, Michigan, USA ALTER Peter Frith, MD Nicolas Roche, MD Hôpital Cochin Repatriation General Hospital, Adelaide NOT South Australia, Australia Paris, France David Halpin, MD Roberto Rodriguez-Roisin, MD Royal Devon and Exeter Hospital Thorax Institute, Hospital Clinic Devon, UK Univ. Barcelona, Barcelona, Spain M. Victorina López Varela, MD MATERIAL-DO Donald Sin, MD Universidad de la República St. Paul’s Hospital Montevideo, Uruguay Vancouver, Canada Masaharu Nishimura, MD Dave Singh, MD Hokkaido Univ School of Medicine University of Manchester Sapporo, Japan Manchester, UK Claus Vogelmeier, MD COPYRIGHTED Robert Stockley, MD University of Gießen and Marburg University Hospital Marburg, Germany Birmingham, UK GOLD SCIENCE DIRECTOR Jørgen Vestbo, MD Suzanne S. Hurd, PhD Hvidovre University Hospital, Hvidovre, Denmark Vancouver, Washington, USA and University of Manchester Manchester, England, UK Jadwiga A. Wedzicha, MD Univ College London London, UK *Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org ii GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (REVISED 2011) INVITED REVIEWERS David Price, MD University of Aberdeen Joan-Albert Barbera, MD Aberdeen, Scotland, UK Hospital Clinic, Universitat de Barcelona Barcelona Spain Nicolas Roche, MD, PhD University Paris Descartes A. Sonia Buist, MD Paris, France Oregon Health Sciences University Portland, OR, USA Sanjay Sethi, MD State University of New York Peter Calverley, MD Buffalo, NY, USA University Hospital Aintree Liverpool, England, UK GOLD NATIONAL LEADERS (Submitting Comments) Bart Celli, MD Brigham and Women’s Hospital Lorenzo Corbetta, MD Boston, MA, USA University of Florence Florence, Italy M. W. Elliott, MD St. James’s University Hospital Alexandru Corlateanu, MD, PhD Leeds, England, UK State Medical and PharmaceuticalREPRODUCE University Republic of Moldova Yoshinosuke Fukuchi, MD OR Juntendo University Le Thi Tuyet Lan, MD, PhD Tokyo, Japan University of Pharmacy and Medicine Ho Chi MinhALTER City, Vietnam Masakazu Ichinose, MD Wakayama Medical University FernandoNOT Lundgren, MD Kimiidera, Wakayama, Japan Pernambuco, Brazil Christine Jenkins, MD E. M. Irusen, MD Woolcock Institute of Medical Research University of Stellenbosch Camperdown. NSW, Australia South Africa H. A. M. Kerstjens, MD MATERIAL-DO Timothy J. MacDonald, MD University of Groningen St. Vincent’s University Hospital Groningen, The Netherlands Dublin, Ireland Peter Lange, MD Takahide Nagase, MD Hvidovre University Hospital University of Tokyo Copenhagen, Denmark Tokyo, Japan M.Victorina López Varela, MD COPYRIGHTED Ewa Nizankowska-Mogilnicka, MD, PhD Universidad de la República Jagiellonian University Medical College Montevideo, Uruguay Krakow, Poland Maria Montes de Oca, MD Magvannorov Oyunchimeg, MD Hospital Universitario de Caracas Ulannbatar, Mongolia Caracas, Venezuela Mostafizur Rahman, MD Atsushi Nagai, MD NIDCH Tokyo Women’s Medical University Mohakhali, Dhaka, Bangladesh Tokyo, Japan Dennis Niewoehner, MD Veterans Affairs Medical Center Minneapolis, MN, USA iii PREFACE In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was presented in the original 2001 document. Updated reports released in January 2013, January 2014, and January 2015 are based on scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. Assessment of COPD is based on the patient’s level of symptoms, future risk of exacerbations, the severity of the spirometric abnormality, and the identification of comorbidities. The 2015 update adds an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees. The GOLD report is presented as a “strategy document” for health care professionals to use as a tool to implement effective management programs based on available health care systems. The quadrant management strategy tool presented in this report is designed to be used in any clinical setting; it draws together a measure of the impact of the patient’s symptoms and an assessment of the patient’s risk of having a serious adverse health event in the future. Many studies have assessed the utility/relevance of this new tool; the main observations of these studies are shown in the table. Evidence will continue to be evaluated by the GOLD committees and management strategy recommendations modified as required. Table: Summary Observations Refs. GOLD has been fortunate to have a network of international Choice of symptom measure (mMRC vs. CAT) influ- 2-5 distinguished healthREPRODUCE professionals from multiple disciplines. ence category assignment Many of these experts have initiated investigations of the OR The prevalence of the four GOLD groups depends on 2;4-10 causes and prevalence of COPD in their countries, and have the specific population studied, C being consistently developed innovative approaches for the dissemination and the least prevalent implementationALTER of the GOLD management strategy. The Groups differed in several clinical, functional, imaging 4;11;12 GOLD initiative will continue to work with National Leaders and biological characteristics in addition to those used andNOT other interested health care professionals to bring COPD for their definition, including comorbidities to the attention of governments, public health officials, health Prevalence of comorbidities and persistent systemic 11 care workers, and the general public to raise awareness inflammation were highest in group B. of the burden of COPD and to develop programs for early The new classification systems correlates with exer- 5 detection, prevention and approaches to management. cise capacity MATERIAL-DO A and D groups were relatively stable over time, where- 11 as groups B and C showed more temporal variability Good prediction of exacerbations during follow-up 13 Marc Decramer, MD Conflicting results in relation to its capacity to predict 5-7;14 Chair, GOLD Board of Directors mortality Professor of Medicine B patients consistently have a mortalityCOPYRIGHTED and hospital- 11;13 CEO University Hospital Leuven ization rate similar to C patients University of Leuven, Leuven, Belgium Prescription appropriateness by GPs (in Italy) is better 9 using new GOLD classification. A real world observational study in five European 10 countries and US identifies the frequent and potentially inappropriate use of inhaled steroids and bronchodila- tors in patients at low risk of exacerbations (A and B) Claus Vogelmeier, MD Chair GOLD Science Committee Director, Internal Medicine Clinic University of Gießen and Marburg, School of Medicine Standort Marburg Baldingerstraße D-35043 Marburg Germany iv REFERENCES 1: Agusti A, Hurd S, Jones P, Fabbri LM, Martinez F, Vogelmeier C et al. FAQs about the GOLD 2011 assessment proposal of COPD: a comparative analysis of four different cohorts. Eur Respir J 2013 November;42(5):1391-401. 2: Han MK, Mullerova H, Curran-Everett D, Dransfield DT, Washko GR, Regan EA et al. GOLD 2011 disease severity classification in COPDGene: a prospective cohort study. The Lancet Respir Med 2013;1:43-50. 3: Jones PW, Adamek L, Nadeau G, Banik N. Comparisons of health status scores with MRC grades in COPD: implications for the GOLD 2011 classification. Eur Respir J 2013 September;42(3):647-54. 4: Jones PW, Nadeau G, Small M, Adamek L. Characteristics of a COPD population categorised using the GOLD framework by health status and exacerbations. Respir Med 2014 January;108(1):129-35. 5: Nishimura K, Oga T, Tsukino M, Hajiro T, Ikeda A, Jones PW. Reanalysis of the Japanese experience using the combined COPD assessment