Global Initiative for Chronic Obstructive Lung D isease GOLD 2017 Report GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE 2017 REPORT Visit the GOLD website at www.goldcopd.org © 2017 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 (2017 REPORT) © 2017 Global Initiative for Chronic Obstructive Lung Disease, Inc. ii GOLD BOARD OF DIRECTORS GOLD SCIENCE COMMITTEE* (2016) (2016) 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 Marc Decramer, MD, Chair (to 05/16) Clinic, IDIBAPS Paris, France University of Leuven Univ. Barcelona and Ciberes Leuven, Belgium Barcelona, Spain Roberto Rodriguez-Roisin, MD Respiratory Institut, Hospital Bartolome R. Celli, MD Antonio Anzueto, MD Clinic, Brigham and Women’s Hospital Boston, University of Texas IDIBAPS, Univ. Barcelona and Massachusetts, USA Health Science Center Ciberes San Antonio, Texas, USA Barcelona, Spain Rongchang Chen, MD Guangzhou Institute of Respiratory Peter Barnes, MD Donald Sin, MD Disease National Heart and Lung Institute St. Paul’s Hospital, University of Guangzhou, PRC London, United Kingdom British Columbia Vancouver, Canada Gerard Criner, MD Jean Bourbeau, MD Temple University School of Medicine McGill University Health Centre Dave Singh, MD Philadelphia, Pennsylvania, USA Montreal, Canada University of Manchester Manchester, UK Peter Frith, MD Gerard Criner, MD Repatriation General Hospital, Adelaide, Temple University School of Medicine Robert Stockley, MD South Australia, Australia Philadelphia, Pennsylvania, USA University Hospital Birmingham, UK David Halpin, MD Leonardo M. Fabbri, MD Royal Devon and Exeter Hospital University of Modena & Reggio Emilia Jørgen Vestbo, MD Devon, UK Modena, Italy University of Manchester Manchester, England, UK M. Victorina López Varela, MD Fernando Martinez, MD, MS Universidad de la República New York-Presbyterian Hospital/ Jadwiga A. Wedzicha, MD Montevideo, Uruguay Weill Cornell Medical Center Imperial College London New York, NY USA London, UK Masaharu Nishimura, MD Hokkaido University School of Medicine Sapporo, Japan Roberto Rodriguez-Roisin, MD Respiratory Institute, Hospital Clinic, IDIBAPS Univ. Barcelona and Ciberes Barcelona, Spain Claus Vogelmeier, MD University of Marburg Marburg, Germany GOLD PROGRAM DIRECTOR Rebecca Decker, MSJ Fontana, Wisconsin, USA Suzanne Hurd, PhD (Director to 12/15) * Disclosure forms for GOLD Committees are posted on the GOLD Website, www.goldcopd.org iii GLOBAL STRATEGY FOR THE DIAGNOSIS, MANAGEMENT, AND PREVENTION OF COPD (2017 REPORT) GOLD NATIONAL LEADERS Perlat Kapisyzi, Albania Bashar Nsour, Jordan Eduardo A. Schiavi, Argentina Jawad Hamad, Jordan Otto Chris Burghuber, Austria Damilya Nugmanova, Kazakhstan Mostafizur Rahman, Bangladesh Yeon-Mok Oh, Korea Kazi S. Bennoor, Bangladesh Mousa Khadadah, Kuwait Wim Janssens, Belgium Talant Sooronbaev, Kyrgyz Republic Jose Roberto Jardim, Brazil Joseph M Cacciottolo, Malta Aquiles Camelier, Brazil J. Javier Díaz Castañón, Mexico Fernando Lundgren, Brazil Alexandru Corlateanu, Moldova Yavor Ivanov, Bulgaria Dr Oyunchimeg, Mongolia Kosta Kostov, Bulgaria Harold Rea, New Zealand Dennis E. O’Donnell, Canada Jorge Cuadra, Nicaragua Manuel Barros, Chile Amund Gulsvik, Norway Nan-Shan Zhong, China Ernst Omenaas, Norway Jiangtao Lin, China Javaid Khan, Pakistan Chunxue Bai, China Jamil Ur Rehman Tahir, Pakistan Fu-Qiang Wen, China Mohammad Osman Yusuf, Pakistan Alejandro Casas, Colombia Teresita S. deGuia, Philippines Neven Miculinic, Croatia Ewa Nizankowska-Mogilnicka, Poland Stanislav Kos, Czech Republic Pawel Kuca, Poland Jaromir Musil, Czech Republic Florin Mihaltan, Romania Vladimir Vondra, Czech Republic Ruxandra Ulmeanu, Romania Ejvind Frausing Hansen, Denmark Alexander Chuchalin, Russia Eduardo Gautreau de Windt, Dominican Republic Dmitri R. Rackita, Russia Hisham Tarraf, Egypt Professor Alexandre Vizel, Russia Victor Castro Gòmez, El Salvador Professor Eugeny Shmelev, Russia Gerard Huchon, France Kian-Chung Ong, Singapore Maia Gotua, Georgia Wan-Cheng Tan, Singapore Klaus Rabe, Germany Ruzena Tkacova, Slovak Republic David S.C. Hui, Hong Kong Stanislav Suskovic, Slovenia Thorarinn Gislason, Iceland EM Irusen, South Africa Gunnar Gudmundsson, Iceland Patricia Sobradillo, Spain Rohini V. Chowgule, India Daiana Stolz, Switzerland R.Narasimhan, India Yousser Mohammad, Syria Faisal Yunus, Indonesia Professor Ali Kocabas, Turkey Masjedi Mohammad Reza, Iran Hakan Gunen, Turkey Mohammad Ashkan Moslehi, Iran Maria Montes de Oca, Venezuela Timothy J. McDonnell, Ireland Ngo Quy Chau, Vietnam Zvi G. Fridlender, Israel Le Thi Tuyet Lan, Vietnam Lorenzo Corbetta, Italy Sy Duong-Quy, Vietnam Takahide Nagase, Japan Khaled Al-Shair, Yemen Michiaki Mishima, Japan 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 is proposed in this 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 use as a tool to implement effective management 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 in this 2017 GOLD Report will continue to be evaluated by the GOLD committees and management strategy recommendations will be modified as required as new data become available. GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence of COPD in their countries, and have developed innovative approaches for the v dissemination and implementation of the GOLD management strategy. The GOLD initiative will continue to work with National Leaders and other interested healthcare professionals to bring COPD to the attention of governments, public health officials, healthcare workers, and the general public to raise awareness of the burden of COPD and to develop programs for early detection, prevention and approaches to management. Alvar G. Agusti, MD Claus Vogelmeier, MD Chair, GOLD Board of Directors Chair, GOLD Science Committee Hospital Clínic, Department of Medicine, Universitat de Barcelona, Pulmonary and Critical Care Medicine Villarroel 170, 08036 University Medical Center Gießen and Barcelona, Spain Marburg Philipps-Universität Marburg, Baldingerstraße 35043 Marburg, Germany vi Summary of publications that have examined the ABCD grading system References since its implementation in 2011 Choice of symptom measure (mMRC vs. CAT) influence category assignment 2-5; 19 The prevalence of the four GOLD groups depends on the specific population 2;4-10 studied, C being consistently the least prevalent Groups differed in several clinical, functional, imaging and biological