Twenty Years of Changes in the Disease Assessment Method of the Global Initiative for Chronic Obstructive Lung Disease

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Twenty Years of Changes in the Disease Assessment Method of the Global Initiative for Chronic Obstructive Lung Disease

Chronic Obstructive Pulmonary Disease (COPD) is a significant global health concern. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been at the forefront of providing guidelines for its management. Over the past twenty years, GOLD has undergone several revisions, with the most significant changes related to the COPD disease assessment method.

Introduction

The first version of GOLD was released in 2001, providing guidance for standardized diagnosis and treatment. GOLD 0 was defined as a high – risk period of COPD and included in the spirometric grading system. Since then, GOLD undergoes major revisions every 4 to 5 years and is updated annually. The key changes in the disease assessment method were made in 2006, 2011, and 2017.

In 2006, GOLD updated the definition of COPD, evaluation by spirometry, and pathogenesis and treatment strategy, classifying COPD into four levels (GOLD I – GOLD IV) according to pulmonary function. In 2011, GOLD significantly updated the assessment method and management, including symptoms and exacerbation history in the comprehensive assessment. In 2017, the assessment system was revised again, removing spirometric grades and classifying patients only according to symptoms and exacerbation history.

Update of the Assessment System of COPD in GOLD

  • GOLD 2011 ABCD Assessment Tool: This was a major advance from the simple spirometric grading system. It incorporated multi – modality assessment and symptom burden, highlighting the importance of exacerbation prevention. Evidence supported this classification, such as patients with a high risk of exacerbations tending to be in GOLD categories 3 and 4 (severe or very severe airflow limitation) and being identifiable from their history. Higher exacerbation rates were associated with faster loss of forced expiratory volume in the first second (FEV1) and greater worsening of health status. COPD Assessment Test (CAT) scores ≥10 were associated with significantly impaired health status.
  • Limitations of GOLD 2011: However, over time, limitations were found. The 2011 ABCD assessment tool was not superior to spirometric grades for mortality prediction or other important health outcomes. The prognosis of groups C and D was determined by two indicators (spirometry and exacerbation history), causing confusion. Spirometry results could not fully reflect individual clinical differences, and spirometry alone could not accurately predict the risk of COPD.

To address these concerns, the GOLD 2017 report proposed a new refined ABCD assessment tool, separating spirometric grades from the ABCD groups.

Changes due to the Update of the New Assessment System of COPD in GOLD

  • Distribution of Subgroups: The new assessment tool profoundly affected the distribution of patients. Studies such as Tudoric et al’s analysis of the POPE study, Sun et al’s stratification of Chinese patients, Cabrera López et al’s follow – up study, and Tan et al’s analysis of the Canadian cohort all showed that more patients in the high – risk group were classified to the low – risk group according to GOLD 2017.
  • Clinical Characteristics: Sun et al found that the new high – risk groups in GOLD 2017 had more characteristics associated with high risk of acute exacerbation and mortality. Kobayashi et al showed that high – risk patients had lower body mass index, more symptoms, used more respiratory medications, and had more severe airflow limitation. Tan et al revealed that the mean declines in FEV1 for GOLD 2017 categories B and D were significantly greater than A. Hu et al showed that groups B and D had lower lung function, 6 – min walk distance (6MWD), respiratory muscle strength, quality of life, and higher symptom scores and BODE index. Cabrera López et al found that in GOLD 2017, groups D and B had similar BODE index values, and the differences between groups B and D and groups A and C became less.
  • Effect on Treatment: Hsieh et al’s retrospective analysis in Taiwan showed that the pharmacologic concordance rate decreased, and over – treatment increased. Physicians should re – examine treatment patterns for reclassified patients. GOLD 2017 recognized that FEV1 can be used to guide therapy in selected circumstances. GOLD 2019 offered major changes to the medication pathway, providing personalized pharmacologic treatment. Halpin et al’s analysis using GOLD 2019 showed that there was substantial movement of patients between groups, and long – acting muscarinic antagonist monotherapy was common.
  • Prognostic Significance: Cabrera López et al revealed that in GOLD 2017, grade B and grade D had similar mortality rates, while grade C and grade A had significantly lower mortality. Han et al found that GOLD 2017 classification performed well in identifying individuals at risk of exacerbations but had poor predictive ability for mortality. Kobayashi et al also provided evidence that it identified patients at risk of exacerbations but had poor mortality prediction ability.

How to Optimize the Assessment System of COPD

After updating the assessment method, more than one – third of patients in groups C and D were reclassified. The COPD assessment system in the future should be multi – dimensional.

  • Clinical Phenotype Classification: Clinical phenotypes of COPD vary. Classical phenotypes include chronic bronchitis, emphysema, and the blue bloater. New phenotypes include frequent exacerbator, the fast decliner, inflammatory phenotype, current smoker phenotype, systemic or co – morbidities phenotype, and asthma – COPD overlap syndrome. The frequency of exacerbations in patients with chronic bronchitis phenotype is higher. Comorbidity increases the risk of mortality.
  • Image Phenotype Evaluation: Structural computed tomography (CT) can identify emphysema and airways disease phenotypes. Functional CT can identify gas trapping, ventilation, and perfusion phenotypes. Magnetic resonance imaging using hyperpolarized noble gases and conventional methods helps phenotype patients. Pulmonary artery diameter to aorta diameter ratio (PA/A) >1 on chest CT is associated with the risk of future exacerbations.
  • BODE Index: BODE index has good prognostic value. 6MWD, representing exercise capacity, helps identify high – risk patients. 6MWD and speed are prognostic predictors independent of the ABCD group.
  • Spanish Guidelines: The Spanish guidelines presented four clinical phenotypes of high – risk patients and suggested a more individualized approach.

Conclusions

After nearly two decades of revisions, GOLD has moved from single assessment using spirometry to a more comprehensive assessment (spirometry, symptoms, exacerbation history), and then to separating spirometry from the ABCD groups. The new ABCD assessment tool highlights symptoms and exacerbation history. Spirometry remains vital for diagnosis, prognosis, and consideration of other therapeutic approaches. The effect of changes in treatment strategy on prognosis remains to be clarified. The assessment system could be optimized by further identifying phenotypes for a more personalized COPD management approach.

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