Reference: April 2024 | Issue 4 | Vol 10 | Page 39
The 2024 Global Initiative for Obstructive Lung Disease (GOLD) report has been published and contains several further key changes after major amendments made in the 2023 report. GOLD has released an annual report based on the best available evidence in the diagnosis and management of chronic obstructive pulmonary disease (COPD) since 2001. The latest document contains three new sections on hyperinflation, COPD screening in targeted populations, and pharmacotherapies for smoking cessation, as well as 148 new references.
Chapter 3 (Evidence supporting prevention and maintenance therapy) and Chapter 4 (Management of stable COPD) have been merged into a single chapter (new Chapter 3: Prevention and Management of COPD). The algorithms for assessment and treatment of COPD, as well as its definition, remain unchanged. GOLD continues to use the new ‘ABE’ assessment and classification system that was introduced in 2023 and recognises the impact of exacerbation frequency on COPD outcomes (Figure 1).
GOLD 2024 continues to confirm a diagnosis of COPD by the presence of irreversible airflow limitation and a post-bronchodilator forced expiratory volume in one second (FEV1)/forced vital capacity (FVC) <0.7. The document does, however, acknowledge the ongoing debate as to whether the use of the lower limit of normal of the FEV1/FVC ratio would be more appropriate than the currently recommended ratio of 0.7.
It also acknowledges the controversial data regarding a diagnosis of COPD based on pre- or post-bronchodilator spirometry findings. Overall, GOLD 2024 recommends a combined approach to suspected COPD that includes spirometry, validated questionnaires, and exacerbation history. The section on spirometry now provides guidance about when to conduct post-bronchodilator spirometry based on pre-bronchodilator findings.
FIGURE 1: GOLD ABE
Pre-COPD and PRISm
Preserved ratio impaired spirometry (PRISm) – which refers to a reduced FEV1 with a preserved FEV1/FVC ratio after bronchodilation – is associated with increased morbidity and mortality, and information about PRISm has been expanded in GOLD 2024. The document notes that PRISm is not always a stable phenotype and may progress to either obstructed or normal spirometry, highlighting that people with PRISm should be considered patients despite the fact that not all pre-COPD and PRISm progresses to airway obstruction. GOLD also emphasises the major deficit in evidence regarding best practice for these patients.
Hyperinflation
A new section on hyperinflation has been added to the latest GOLD report. Hyperinflation is described as common in COPD patients and attributable to increased gas volume at the end of spontaneous expiration. GOLD 2024 considers hyperinflation to be clinically relevant in COPD and a contributor to many of its typical symptoms. The document identifies an array of treatment strategies, including bronchodilation, supplemental oxygen, heliox, pulmonary rehabilitation, and several breathing techniques, as well as lung reduction bronchoscopy or surgery, to treat and manage hyperinflation.
Blood eosinophil count
In the initial assessment section, the paragraphs on blood eosinophil count have been updated. Blood eosinophil counts are recommended by GOLD to guide the use of inhaled corticosteroids (ICS) in view of the existing data supporting that eosinophil counts “predict the magnitude of the effect of ICS”. Evidence suggesting that patients with COPD may have increased average blood eosinophil counts, which may be associated with increased lung eosinophil numbers and inflammatory markers in the airways, is also described.
Screening for COPD
A new section on screening for COPD in targeted populations has been added to the GOLD 2024 document. Further information on leveraging lung cancer imaging and screening in targeted populations for COPD screening, including spirometry screening, is included in this section, with references to the evidence suggesting that large volumes of people screened for lung cancer have undiagnosed COPD. Recent data is noted that found 57 per cent of 986 individuals who were screened for lung cancer with low dose CT and forced spirometry had evidence of COPD and that 67 per cent of these individuals had never been diagnosed.
Interstitial lung abnormalities (ILA)
GOLD 2024 highlights that in the COPD gene cohort of 4,360 people, 8 per cent had ILAs, with half of these meeting the criteria for interstitial lung disease (ILD). Those with suspected ILD had a high mortality and increased respiratory symptoms. GOLD recommends clinical evaluation, risk stratification, and follow-up monitoring for these patients.
Smoking cessation
The section on smoking cessation has been revised to reflect current evidence and observation and a new section on pharmacotherapies for smoking cessation has been added to the latest document. GOLD 2024 highlights the data supporting the efficacy of a dual approach with counselling and pharmacotherapy and places emphasis on the new pharmacological treatments. The revised document does not consider e-cigarette use (vaping) as a potential strategy and it is not encouraged as a smoking cessation tool.
Vaccination
Vaccination recommendations have been updated in line with current guidance from the US Centre for Disease Control (CDC). Notably, GOLD 2024 now recommends the vaccination of COPD patients with the new respiratory syncytial virus vaccines, as well as those vaccines already recommended in GOLD 2023.
Inhaled pharmacologic therapy
The section on managing inhaled therapy has been expanded, with a key focus on the importance of patient education and training in inhaled device technique. GOLD 2024 prioritises an individual approach to device selection and consideration of the patient’s ability to use the delivery system correctly, as well as reassessment of technique at every opportunity. The document also highlights environmental considerations and recommends choosing the most sustainable and environmentally-friendly inhalers when possible. In combination therapy, use of a single inhaler is preferred over multiple inhalers.
The full GOLD 2024 report can be accessed at: www.goldcopd.org/2024-gold-report/.
