GOLD

Clasification

Antonio Anzueto MDProfessor MedicineUniversity of Texas

Faculty Disclosures

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

Personal financial interests in commercial entities that are relevant to my presentation:

Boehringer Ingelheim: consultant: advisory board, CurrentGlaxoSmithKline: consultant, advisory board, Research Grant to the

University, CurrentChiesi: consultant, advisory board, Past

Bayer-Schering Pharma: consultant, advisory board, CurrentDey Pharma: consultant, advisory board, Current

Forest laboratories: consultant, advisory board, Current

2000- Staging of COPD: GOLD Guidelines

I: Mild

II: Moderate

III: Severe

IV: Very Severe

•FEV1 80%• With or without

symptoms

•FEV1 50 - 79%• With or without

symptoms

•FEV1 30 - 49%• With or without

symptoms

•FEV1 <30%

• Or presence of chronic

respiratory failure or right heart

failure

Active reduction of risk factor(s); Influenza vaccinationAdd 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 CRFConsider surgical treatments

Agusti A et al. Respiratory Research 11 (1):122-136, 2010

GOLD - Goal of COPD Management

Overall COPD Control

Current Control Future Risk

Symptoms

Activity

QoL

Lung function

Exacerbations

Progressionof the disease

Mortality

Medication adverse effects

achieving reducing

defined by defined by

GOLD 2011 www.goldcopd.org

Time for change

Preventative: Tackle the root cause

Approach: Fundamentally shift the

way we treat COPD

1

2

GOLD Assessment

Sev

erit

y o

f A

irfl

ow

O

bst

ruct

ion

Worse obstruction

More severe

Exa

cerb

atio

ns

Frequent exacerbations

DSevere ObstructionSevere Symptoms++ Exacerbations

High

High

High

Risk

Risk

Risk

Symptoms

CSevere ObstructionMinimal Symptoms++ Exacerbations

AMild-Mod

ObstructionMinimal SymptomsFew Exacerbations

BMild-Mod Obstruction

Severe SymptomsFew Exacerbations

GOLD Website. http://www.goldcopd.com. Updated December 2012

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

A B C D0

5

10

15

20

25

30

35

40

COPD CohortPrimary Care

% o

f S

ub

ject

s

GOLD Groups Agusti et al ERJ 2013; 42:1391Haughney et al ERJ 2014; 43:993

Jones et al. ERJ 2013; 42: 647-654

Comparison of CAT and MRC

Assess risk of

exacerbations

Risk of exacerbations

Lange et al. AJRCCM 2012; 186; 975-981

Hurst et al. NEJM 2010; 363: 1128-38

Risk of exacerbations

Han et al. Lancet Infect Dis 2013; 1: 43-50

GOLD classification

GOLD Risk Categories using SGRQ

Han et al Lancet Respiratory 2012

CT Scan Correlated: Emphysema

COPD gene database

A

D

B

C

GOLD Stages: Microbiology by cultures and PCR during an Exacerbation

A B C D Total0

10

20

30

40

50

60

70

80

CulturesPCR

% P

atie

nts

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

Soriano et al. Chest 2013; 143:694-702

Mortality at 10 years follow-up of GOLD D COPD patients

Lange et al. AJRCCM 2012; 186: 975-981

GOLD classification

mMRC 0-1 mMRC ≥2

A 3 (3 %) B 18 (18 %)

C 1 (1 %) D 80 (78%)

Mortality DistributionS

PIR

OM

ET

RIC

R

ISK

GO

LD

STA

GE

1 &

2

GO

LD

STA

GE

3

& 4

P Lange et al Am. J. Respir. Crit. Care Med.2012;186: 975-981

Agusti et al. ERJ 2013; 42: 636-646

Outcomes according to GOLD

ROC Mortality Risk: GOLD 2007 vs 2011

Johannessen et al. AJRCCM 2013; 188:51-59

Treatment

Agusti et al. ERJ 2013; 42: 636-646

Treatment according to GOLD

Add ICS if exacerbations

1st choice:ICS+LABA or LAMA

C: 70% FEV1<50%D: 63% FEV1<50%

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 is a dynamic process that

Evolves with th

e disease

GOLD 2014:Antocholinergics

2013 2014

http://www.goldcopd.org/. Document 2014 Revision, Page 23

GOLD 2014:Anticholinergics – Adverse Events2013 2014

2013 Tiospir study – clarify adverse eventos of Spiriva Respimat

http://www.goldcopd.org/. Document 2014 Revision, Page 23

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.