COPYRIGHTED MATERIAL- DO NOT COPY OR DISTRIBUTE GLOBAL INITIATIVE FOR CHRONIC OBSTRUCTIVE LUNG DISEASE GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (2018 REPORT) COPYRIGHTED MATERIAL- DO NOT COPY OR DISTRIBUTE © 2018 Global Initiative for Chronic Obstructive Lung Disease, Inc. ii GOLD BOARD OF DIRECTORS GOLD SCIENCE COMMITTEE* (2017) (2017) Alvar Agusti, MD, Chair Claus Vogelmeier, MD, Chair Respiratory Institute, University of Marburg Hospital Clinic, IDIBAPS Marburg, Germany Univ. Barcelona and Ciberes Barcelona, Spain Alvar Agusti, MD Nicolas Roche, MD Respiratory Institute, Hospital Hôpital Cochin Bartolome R. Celli, MD Clinic, IDIBAPS Paris, France Brigham and Women’s Hospital Boston, Univ. Barcelona and Ciberes Massachusetts, USA Barcelona, Spain Donald Sin, MD St. Paul’s Hospital, University of Rongchang Chen, MD Antonio Anzueto, MD British Columbia Guangzhou Institute of Respiratory University of Texas Vancouver, Canada Disease Health Science Center Guangzhou, PRC San Antonio, Texas, USA Dave Singh, MD University of Manchester Gerard Criner, MD Peter Barnes, MD Manchester, UK Temple University School of Medicine National Heart and Lung Institute Philadelphia, Pennsylvania, USA London, United Kingdom Robert Stockley, MD University Hospital Peter Frith, MD Jean Bourbeau, MD Birmingham, UK Repatriation General Hospital, Adelaide, McGill University Health Centre South Australia, Australia Montreal, Canada Jørgen Vestbo, MD University of Manchester David Halpin, MD Gerard Criner, MD Manchester, England, UK Royal Devon and Exeter Hospital Temple University School of Medicine Devon, UK Philadelphia, Pennsylvania, USA Jadwiga A. Wedzicha, MD Imperial College London M. Victorina López Varela, MD Peter Frith, MD London, UK Universidad de la República Repatriation General Hospital, Montevideo, Uruguay Adelaide, M. Victorina López South Australia,Australia Varela,MDUniversidad de la Masaharu Nishimura, MD República Hokkaido University School of Medicine David Halpin, MD Hospital Maciel Sapporo, Japan Royal Devon and Exeter Hospital, Montevideo, Uruguay Devon, United Kingdom Claus Vogelmeier, MD University of Marburg Fernando J. Martinez, MD, MS Marburg, Germany New York-Presbyterian Hospital/ Weill Cornell Medical Center New York, NY USA COPYRIGHTED MATERIAL- DO NOT COPY OR DISTRIBUTE GOLD PROGRAM DIRECTOR Rebecca Decker, MSJ Fontana, Wisconsin, USA * Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (2017) GOLD NATIONAL LEADERS ALBANIA DOMINICAN REPUBLIC KUWAIT Professor Perlat Kapisyzi Dr. Eduardo Gautreau de Windt Professor Mousa Khadadah Tirana, Albania Provincia Santo Domingo, Kuwait University ARGENTINA Dominican Republic KYRGYZSTAN Dr. Eduardo A. Schiavi EGYPT Talant Sooronbaev, MD Buenos Aires, Argentina Hisham Tarraf, MD Bishkek, Kyrgyzstan AUSTRALIA Cairo, Egypt MALTA Peter Frith, MD EL SALVADOR Prof Joseph M Cacciottolo Adelaide, South Australia, Australia Dr. Victor Castro Gòmez Pieta, Malta AUSTRIA San Salvador, El Salvador MEXICO Dr. Otto Chris Burghuber FRANCE Dr. J. Javier Díaz Castañón BANGLADESH Professor Gerard Huchon Zapopan, Jalisco, Mexico Prof. Md. Mostafizur Rahman Paris, France MOLDOVA Dhaka, Bangladesh GEORGIA Alexandru Corlateanu, MD, PhD Dr. Kazi S. Bennoor Maia Gotua, MD, PhD ERS National Delegate Dhaka, Bangladesh Tbilisi, Georgia Republic of Moldova BELGIUM HONG KONG CHINA MONGOLIA Professor Wim Janssens David S.C. Hui, MD Dr. Oyunchimeg Leuven, Belgium Shatin, N.T. Hong Kong Chair of International Cooperation BRAZIL ICELAND NEPAL Dr. Jose Roberto Jardim Thorarinn Gislason, MD, PhD Dr. M. R. Pandey Sao Paulo, Brazil Reykjavik, Iceland Kathmandu, Nepal Aquiles Camelier, MD Dr Gunnar Gudmundsson NETHERLANDS Fernando Lundgren, MD Reykjavik, Iceland Klaus Rabe, MD BULGARIA INDIA Leiden, The Netherlands Dr. Yavor Ivanov Rohini V. Chowgule, MD NEW ZEALAND Pleven, Bulgaria Mumbai, India Harold Rea, MD Dr. Kosta Kostov Dr. R. Narasimhan, MD Auckland, New Zealand Sofia, Bulgaria Chennai, India NICARAGUA CANADA INDONESIA Dr. Jorge Cuadra Dr. Dennis E. O’Donnell Professor Faisal Yunus Sociedad Nicaraguense Kingston, Ontario, Canada IRAN NORWAY CHILE Dr. Masjedi Mohammad Reza Amund Gulsvik, MD Dr. Manuel Barros Tehran, Iran Bergen, Norway CHINA Dr. Mohammad Ashkan Moslehi Ernst Omenaas, MD Chunxue Bai, MD, PhD Shiraz, Iran Bergen, Norway Shanghai, China IRELAND PAKISTAN Jiangtao Lin, MD Timothy J. McDonnell, MD Professor Javaid Khan Beijing, China Dublin, Ireland Karachi, Pakistan Fu-Qiang Wen, MD, PhD ISRAEL Dr. Jamil Ur Rehman Tahir Chengdu, Sichuan, China Zvi G. Fridlender, MD, MSc Kammanwala, Sialkot Cantt, Nan-Shan Zhong, MD Jerusalem, Israel Dr. Mohammad Osman Yusuf Guangzhou, China COPYRIGHTED MATERIAL-ITALY DO NOT COPY OR DISTRIBUTEIslamabad, Pakistan COLOMBIA Professor Lorenzo Corbetta PHILIPPINES Alejandro Casas, MD Florence Teresita S. deGuia, MD Vice-Director, COPD Department JAPAN Quezon City, Philippines Latin American Thoracic Society Takahide Nagase, MD POLAND CROATIA Tokyo, Japan Ewa Nizankowska-Mogilnicka, MD, Neven Miculinic, MD Michiaki Mishima, MD PhD, Krakow, Poland Zagreb, Croatia Kyoto, Japan Paul Kuca, MD CZECH REPUBLIC JORDAN Warsaw, Poland Stanislav Kos, MD, PhD, FCCP Bashar Nsour, MD ROMANIA Mirosov, Czech Republic Amman, Jordan Florin Mihaltan, MD Jaromir Musil, MD Jawad Hamad, MD Bucharest, Romania President, Czech Association Against Amman, Jordan Ruxandra Ulmeanu, MD COPD KAZAKHSTAN Bucharest, Romania Vladimir Vondra, MD, PhD Damilya Nugmanova, MD, PhD, DSci RUSSIA Prague, Czech Republic Almaty, Kazakhstan Alexander Chuchalin, MD DENMARK KOREA Moscow, Russia Ejvind Frausing Hansen, MD Yeon-Mok Oh, MD Professor Dmitri R. Rackita, MD, Hvidovre, Denmark Seoul, South Korea PhD, Ryazan, Russia Professor Alexandre Vizel, MD Professor E.M. Irusen URUGUAY Kazan, Tatarstan Republic Tygerberg, South Africa Mará Victorina López, MD Professor Eugeny Shmelev, MD SPAIN Montevideo, Uruguay SINGAPORE Dr. Patricia Sobradillo VENEZUELA Dr. Kian-Chung Ong SWITZERLAND Maria Montes de Oca, MD Wan-Cheng Tan, MD, Daiana Stolz, MD Caracas, Venezuela Chair, Asian Pacific COPD Basel, Switzerland VIETNAM Roundtable SYRIA Ngo Quy Chau, MD, PhD SLOVAK REPUBLIC Yousser Mohammad, MD Hanoi, Vietnam Ruzena Tkacova, MD PhD Lattakia, Syria Le Thi Tuyet Lan, MD, PhD Kosice, Slovakia TURKEY Ho Chi Minh City, Vietnam SLOVENIA Professor Ali Kocabas, MD YEMEN Professor Dr. Stanislav Suskovic Balcali, Adana, Turkey Khaled Al-Shair, MD Golnik, Slovenia Prof. Dr. Hakan Gunen SOUTH AFRICA Malatya, Turkey COPYRIGHTED MATERIAL- DO NOT COPY OR DISTRIBUTE v 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 first presented in the original 2001 document. Reports released in January 2013, January 2014, January 2015, and January 2016 were based on updated scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. The 2015 update added an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees. The assessment of COPD proposed by GOLD has been based on the patient’s level of symptoms, future risk of exacerbations, the extent of airflow limitation, the spirometric abnormality, and the identification of comorbidities. The “ABCD” assessment tool of the 2011 GOLD update was a major advance from the simple spirometric grading system of the earlier versions of GOLD because it incorporated multimodality assessment, symptom burden and highlighted the importance of exacerbation prevention in the management of COPD. However, there were some important limitations to this scheme. The ABCD assessment tool performed no better than spirometric grades for mortality prediction or other important health outcomes. To address these and other concerns (while at the same time maintaining consistency and simplicity for the practicing clinician), a refinement of the ABCD assessment tool was proposed in the 2017 GOLD Report that separates spirometric grades from the “ABCD” groups. Thus, ABCD groups and their associated implications for pharmacotherapy recommendations will be derived exclusively from patient symptoms and their history of exacerbations. The separation of airflow limitation from clinical parameters makes it clearer what is being evaluated and ranked. This revised assessment tool acknowledges the limitations of FEV1 in influencing some therapeutic decisions for individualized patient care and highlights the importance of patient symptoms and exacerbation risks in patients with COPD. Spirometry remains key in the diagnosis, prognostication and treatment with nonpharmacologic therapies. The GOLD report has been used worldwide as a “strategy document” for healthcare professionals to useCOPYRIGHTED as a tool to implementMATERIAL- effective DO NOT managementCOPY OR DISTRIBUTE programs based on local healthcare systems. The ABCD assessment tool has been used by many to structure their assessment of COPD symptom burden and create treatment plans. A summary of publications that have examined the ABCD grading system since its first presentation in 2011 is provided in the table on the next page. Additional evidence generated from using the original and the revised system proposed