Transcript No Slide Title

GOLD
Clasification
Antonio Anzueto MD
Professor Medicine
University of Texas
Faculty Disclosures
Personal financial interests in commercial entities that are relevant
to my presentation:
Boehringer Ingelheim: consultant: advisory board, Current
GlaxoSmithKline: consultant, advisory board, Research Grant to the
University, Current
Chiesi: consultant, advisory board, Past
Bayer-Schering Pharma: consultant, advisory board, Current
Dey Pharma: consultant, advisory board, Current
Forest laboratories: consultant, advisory board, Current
Non-commercial, non-governmental interests relevant to my presentation :
Member of the ATS/ERS Task force on COPD and COPD Exacerbations, Current
Member of Scientific Committee of GOLD, Current
2000- Staging of COPD: GOLD Guidelines
I:
Mild
II:
Moderate
III:
Severe
IV:
Very Severe
• FEV1 <30%
• FEV1 80%
• FEV1 50 - 79%
• FEV1 30 - 49%
• With or without
symptoms
• With or without
symptoms
• With or without
symptoms
• Or presence of
chronic
respiratory failure
or right heart
failure
Active reduction of risk factor(s); Influenza vaccination
Add short-acting bronchodilator (when needed)
Add regular treatment with one or more long-acting
bronchodilators (when needed); Add rehabilitation
Add ICS if repeated exacerbations
Add long-term
oxygen if CRF
Consider surgical
treatments
Agusti A et al. Respiratory Research 11 (1):122-136, 2010
GOLD - Goal of COPD Management
Overall COPD Control
achieving
reducing
Current Control
defined by
Future Risk
defined by
Symptoms
QoL
Exacerbations
Mortality
Activity
Lung function
Progression
of the disease
Medication
adverse effects
GOLD 2011 www.goldcopd.org
Time for change
Preventative: Tackle the root cause
Approach: Fundamentally shift the
way we treat COPD
GOLD
Assessment
Frequent
exacerbations
C
D
Severe Obstruction
Minimal Symptoms
++ Exacerbations
Severe Obstruction
Severe Symptoms
++ Exacerbations
A
Mild-Mod
Obstruction
Minimal Symptoms
Few Exacerbations
B
Mild-Mod Obstruction
Severe Symptoms
Few Exacerbations
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2012
Exacerbations
Severity of Airflow
Obstruction
Worse
obstruction
More
severe
Do these groups
exist ?
Frequency distribution of the four patient groups observed in the four
studies
Agusti et al ERJ 2013; 42:1391
Distribution of COPD types
Johannessen et al. AJRCCM 2013; 188:51-59
GOLD Group Distribution
40
% of Subjects
35
30
25
COPD Cohort
Primary Care
20
15
10
5
0
A
B
C
GOLD Groups
D
Agusti et al ERJ 2013; 42:1391
Haughney et al ERJ 2014; 43:993
Comparison of CAT and MRC
Jones et al. ERJ 2013; 42: 647-654
Assess risk of
exacerbations
Risk of exacerbations
Lange et al. AJRCCM 2012; 186; 975-981
Risk of exacerbations
Hurst et al. NEJM 2010; 363: 1128-38
GOLD classification
Han et al. Lancet Infect Dis 2013; 1: 43-50
GOLD Risk Categories using SGRQ
Han et al Lancet Respiratory 2012
CT Scan Correlated: Emphysema
C
D
A
B
COPD gene database
% Patients
GOLD Stages: Microbiology by cultures and
PCR during an Exacerbation
80
70
60
50
40
30
20
10
0
Cultures
PCR
A
B
C
D
Total
GOLD Group
Aydemir et al I J COPD 2014:9 1045–1051
Prognostic
value
GOLD classification
Soriano et al. Chest 2013; 143:694-702
GOLD classification
Mortality at 10
years follow-up of
GOLD D COPD
patients
Soriano et al. Chest 2013; 143:694-702
GOLD classification
Lange et al. AJRCCM 2012; 186: 975-981
SPIROMETRIC RISK
GOLD STAGE 3
GOLD STAGE 1 &2
&4
Mortality Distribution
C 1 (1 %)
A 3 (3 %)
mMRC 0-1
P Lange et al Am. J. Respir. Crit. Care Med.2012;186: 975-981
D 80 (78%)
B 18 (18 %)
mMRC ≥2
Outcomes according to GOLD
Agusti et al. ERJ 2013; 42: 636-646
ROC Mortality Risk: GOLD 2007 vs 2011
Johannessen et al. AJRCCM 2013; 188:51-59
Treatment
Treatment according to GOLD
Add ICS
if exacerbations
1st choice:
ICS+LABA or LAMA
C: 70% FEV1<50%
D: 63% FEV1<50%
Agusti et al. ERJ 2013; 42: 636-646
GOLD D and B: HR Exacerbation Reduction ICS+
LABA vs LABA
Anzueto et al ATS 2014
GOLD D Subgroups: HR Exacerbation Reduction ICS+
LABA vs LABA
Anzueto et al ATS 2014
What do we know of the new GOLD classification
 Prevalence of
the four groups varied between
populations.
 Groups A and D – more stable over time
 Hospitalization and Mortality lowest in A, highest
D, similar B and C
 Comorbidities – more prevalent and
symptomatic in B and D
 Exacerbations increases from A to D
GOLD 2014:
Antocholinergics
2013
http://www.goldcopd.org/. Document 2014 Revision, Page 23
2014
GOLD 2014:
Anticholinergics – Adverse Events
2013
2013 Tiospir study – clarify adverse eventos of Spiriva Respimat
http://www.goldcopd.org/. Document 2014 Revision, Page 23
2014
What we need next GOLD classification:
 Phenotypes
 Co-morbid conditions
 Progression of disease – changes from one
group to another
 De-escalation of therapy
Different Look of COPD!
Agusti A et al. Am J Respir Crit Care Med. 2011;184:(5):507-513.