The new year dawns with new guidelines.Global Initiative for Obstructive Lung Disease (GOLD 2020) has some major and few minor changes to offer for the management of COPD. Global Initiative for Chronic Obstructive Lung Disease: the changes made. New to the 2020 GOLD guidelines are treatment escalation pathways depending on whether the patient has had an exacerbation or dyspnea is not improving or worsening. (B�"��y���*���Z$�\z�A���b�!��$&ȥ����O���\s{g��<>��KDv$��̨GSY���d^�0�m3Y��@ w1T�&�cg{ ��E&���������v���5"3�D�r���
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�`���n����Y�>9��tr�9�2������y�uݓ��W����!��k��b,�U[�8�@{v�. Whereas earlier versions of GOLD placed ICS/LABA as the first line of therapy for GOLD Grades 3 and 4 and (Group C and Group D), the more recent iterations have essentially reserved their use for patients where LAMA and/or LABA fail to reduce exacerbations. The GOLD Committee has provided an abundance of sound evidence-based recommendations for over 18 years and will continue to be a global leader and an invaluable source of information. Wedzicha JA, Calverley PMA, Seemungal TA, Hagan G, Ansari Z, Stockley RA. 15, 2019) ATS 2017 Pulmonary Course - Putting the 2017 GOLD COPD Recommendations into Clinical Practice (expired Jul. Precision medicine in COPD: review of mepolizumab for eosinophilic COPD. Chronic Obstr Pulm Dis. 2019;6(5):400-413. doi: http://dx.doi.org/10.15326/jcopdf.6.5.2019.0150. Studies will need to examine whether there may be other less expensive means to acquire similar information regarding small airway disease, particularly for parts of the world where there may not be access to such technology. disease state. %%EOF
doi: https://doi.org/10.7326/0003-4819-155-2-201107190-02003, 10. 2. Respir Care. The significant changes include defining the role of inhaled corticosteroids (ICS) and vitamin D levels [1]. Management of COPD. 2019;6(5):414-429. doi: https://doi.org/10.15326/jcopdf.6.5.2019.0155, 29. Ferguson GT, Rabe KF, Martinez FJ, et al. Niewoehner DE, Rice K, Cote C, et al. New official guidelines have been published by the American Thoracic Society (ATS) for the treatment of chronic obstructive pulmonary disease (COPD). Using these 4 disease characteristics, 8 categories of participants were identified and evaluated for odds of spirometric disease progression (FEV1 > 350 ml loss over 5 years), and the hazard ratio for all-cause mortality was examined. The proposed COPDGene® 2019 diagnostic criteria would add an additional 3144 participants. COPD Chronic obstructive pulmonary disease . Subtypes of COPD have unique distributions and differential risk of mortality. 2017;49(3):1602486. doi: https://doi.org/10.1183/13993003.02486-2016, 26. 2016;71(2):118-125. doi: https://doi.org/10.1136/thoraxjnl-2015-207021, 22. Yang M, Du Y, Chen H, Jiang D, Xu Z. Thorax. Considering the COPD Foundation endorsement of moving to a new definition of COPD, the next iteration of the COPD Foundation pocket guide is likely to reflect this transition to the COPDGene® 2019 definition. Mehta R, Pefani E, Beerahee M, et al. GOLD 4 - very severe: FEV1 <30% predicted. This will need to be further studied and standardized as far as automated algorithms for calculation of emphysema and small airway disease and its practical application globally. Chronic Obstr Pulm Dis. Dasgupta A, Kjarsgaard M, Capaldi D, et al. Pulmonary subtypes exhibit differential global initiative for chronic obstructive lung disease spirometry stage progression: the COPDGene study. Further, there is little data as to whether a group of these patients has been fully identified and characterized and to know whether or not this group of individuals experience significant exacerbations. If you wish to request information about reproducing figures or tables, please contact Bret Denning, JCOPDF staff member at BDENNING@COPDFOUNDATION.ORG. Thank you for your interest in advertising in Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation. 2018;378(18):1671-1680. doi: https://doi.org/10.1056/NEJMoa1713901, 17. van den Berge M, Kerstjens HA. The COPD Foundation owns the copyright to all content in the JCOPDF, unless otherwise noted. h�b```g``�������� Ā B�@������0)���C�
$y/e�����.�s��{���70 ... (exacerbations). Discussion. 2013;1(3):199-209. doi: https://doi.org/10.1016/S2213-2600(13)70052-3, 8. Wedzicha JA, Decramer M, Ficker J, et al. The EPD-only group was associated with conversion from GOLD 0 to GOLD 1 (OR 2.4, 95% CI 1.2-4.6), and GOLD 1 to GOLD 2-4 (OR 2.6, 95% CI 1.0-6.9). The rationale has been that, while these abnormalities may indicate that these individuals are susceptible to lung injury related to cigarette smoking or other injurious inhalants, (biomass fuels for example), there is little evidence that our current treatment options have much impact on their symptoms or progression of their disease. It has been proposed as a means to improve the precision of determining treatment options for COPD patients. Young KA, Strand MJ, Ragland MF, et al for the COPDGene Investigators. Lowe KE, Regan EA, Anzueto A, et al. Symptoms are assessed using the Modified British Medical Research Council (mMRC) or COPD assessment test (CAT) scale. Among 8157 COPDGene® participants with complete spirometry and computed tomography (CT) measures, the top 2 deciles of the airway-predominant and emphysema-predominant axes previously identified were used to categorize individuals into 3 groups having the highest risk for mortality using Cox proportional hazard ratios. This study by Young and colleagues examined the differences between airway predominant and emphysema predominant CT patterns with regard to disease progression and mortality. 2018;13: 3669-3676. doi: https://doi.org/10.2147/COPD.S179425, 20. If you are interested in ordering (or obtaining a quote for) paper reprints or e-prints of an article, please download and complete the JCOPDF Reprint Quote/Order Form and email it to Bret Denning, JCOPDF staff member at BDENNING@COPDFOUNDATION.ORG. Tiotropium reduced exacerbations more than salmeterol in moderate-to-very severe COPD. There is moderate support for considering use for those with 1 moderate exacerbation and blood eosinophil count between 100-300 cells/mcL. balkissoonr@njhealth.org. Sciurba FC, Bradford ES, Pavord ID. Curr Opin Pulm Med. 2020 Global Strategy for Prevention, Diagnosis and Management of COPD Evidence-based strategy document for COPD diagnosis, management, and prevention, with citations from the scientific literature. Discussions of COPD and COPD management, evidence levels, and specific citations from the scientific literature are included in that source Citation: Balkissoon R. Journal club-COPD2020 update. These findings support the concept that, for at least certain interventions, early detection and commencement of therapy may lead to better long-term outcomes rather than waiting for further progression to occur before initiating treatment. There were 4615 participants who completed a 5-year follow-up with a full set of data including return visits for physiologic and radiographic assessments. Following initiating treatment, escalation or de-escalation of therapy is adjusted according to response to therapy. 31, 2019) Related Press Releases h��ZkO��+�1Q�L�W+ty%�nH�1�������vV���t�1�je��g�US]�Tu�R�BR�B�PH���(e�4�U�,�u��Fi Chronic Obstr Pulm Dis. Please sign up to receive your free digital subscription. Airway-predominant and emphysema-predominant subtypes are highly important in determining patterns of early disease progression. NZ COPD Guidelines 2020: A Quick Reference Guide Robert J Hancox, Stuart Jones, Christina Baggott, ... Spirometry –remains the gold standard Good quality needs to be available Few contraindications ... exacerbations LAMA LABA/LAMA COPD with Frequent exacerbations LAMA LABA/LAMA (consider ICS/LABA if eosinophilia) then Please read our Publications Policy about advertising guidelines. Definition of abbreviation: COPD = chronic obstructive pulmonary disease; GOLD = Global Initiative for Chronic Obstructive Lung Disease. Kuangyu Chen Published at : 24 Dec 2020 . Although the 2020 updates to the GOLD recommendations on COPD management have provided more clarity regarding treatment, ... Women were more likely than men to be diagnosed with chronic obstructive pulmonary disease, and had more frequent exacerbations. 206 views . Surgical options such as lung volume reduction and lung transplantation, and, more recently, bronchoscopic endobronchial valve lung volume reduction have been added. ��1;��b�!u�dA��
S�:ܖ04H0l�����+ŭL�3�MU` -h\���l�.�T�.� 2018;14(4):338-341. doi: https://doi.org/10.1183/20734735.026318, 25. The renewed interest in the last few years to the relevance of the concept of asthma/COPD overlap was in part related to trying to establish greater precision in determining those patients who might be most appropriate for ICS/LABA or ICS/LABA/LAMA therapy but also due to the development of monoclonal antibodies such as the anti-interleukin- 5 ligand and interleukin-5 receptora antagonist and the anti-interleukin-4 receptora antagonist that block pathways important for T-helper 2 (TH-2) cell signaling. Differential conversion occurs from GOLD 0 to PRISm and GOLD 0 to GOLD 1 based on groups expressing airway-predominant disease or emphysema-predominant disease independently or in combination. 2018;6(5):337-344. doi: https://doi.org/10.1016/S2213-2600(18)30102-4, 9. 2018;58(11):1461-1467. doi: https://doi.org/10.1002/jcph.1253, 14. 2019;6(5):414-429. doi: http://dx.doi.org/10.15326/jcopdf.6.5.2019.0155. Chronic Obstr Pulm Dis. Tuberc Respir Dis (Seoul). Ther Adv Respir Dis. It is likely that these documents will inform the New Zealand guidelines to be published later in 2020. �E�?b/X�0�O���(�f����Ȁ�j �e:`Q�t. N Engl J Med. It has been proven for lung cancer; it is quite plausible it will also be found for COPD. 2018;6(11):855-862. doi: https://doi.org/10.1016/S2213-2600(18)30368-0, 19. These individuals are at significant risk of death and spirometric disease progression. Please read the JCOPDF Reprint Options and Policy for reference. N Engl J Med. 2020; 7(1): 64-72. doi: http://doi.org/10.15326/jcopdf.7.1.2020.0133, copd, chronic obstructive pulmonary disease, Global initiative for chronic Obstructive Lung Dis, GOLD, COPD Genetic Epidemiology, COPDGene, Running Head: Journal Club: GOLD 2020 and COPDGene 2019, Abbreviations: chronic obstructive pulmonary disease, COPD; Global initiative for chronic Obstructive Lung Disease, GOLD; forced expiratory volume in 1 second, FEV1; COPD Assessment Test, CAT; long-acting beta2-agonists, LABA; long-acting muscarinic antagonist, LAMA; inhaled corticosteroid, ICS; T-helper 2 cells, TH-2; forced vital capacity, FVC; COPD Genetic Epidemiology study, COPDGene®; computed tomography, CT. The COPDGene® cohort is highly enriched with heavy smokers (average of approximately 50 pack years) with airflow limitation and therefore the findings, including associations and projections, may not be universally applicable to those with lower cigarette, (or biomass), exposure or non-smokers who demonstrate airflow limitation. Cureus. Tiotropium and olodaterol in the prevention of chronic obstructive pulmonary disease exacerbations (DYNAGITO): a double-blind, randomised, parallel-group, active-controlled trial. Miami, Florida 33134. Lancet Respir Med. The study identifies that a substantial number already would meet GOLD criteria for a COPD diagnosis and a significant number would be added using the COPDGene® 2019 definition. Subscribe to Kuangyu Chen. Key items of the initial Rx therapy are introduced using 3D letters and icons. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: National Heart, Lung, and Blood Institute and World Health Organization Global Initiative for Chronic Obstructive Lung Disease (GOLD): executive summary. Blood eosinophils and inhaled corticosteroid/long-acting beta-2 agonist efficacy in COPD. Variability of blood eosinophils as a biomarker in asthma and COPD. The study once again reinforces that patients currently not identified by GOLD classification as having disease warranting pharmacologic intervention, can progress significantly over a 5-year interval. 2019;7(9):722-723. doi: https://doi.org/10.1016/S2213-2600(19)30195-X, 18. The JCOPDF is available free of charge. Definition — the definition remains the same. Respirology. endstream
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2019;77:105950. doi: https://doi.org/10.1016/j.intimp.2019.105950, 4. Interestingly, 3 papers from theCOPDGene® study group were published in a Special Issue of this Journal—Chronic Obstructive Pulmonary Diseases: Journal of the COPD Foundation—in November 2019.27-29 The papers present thought-provoking data compelling us to rethink whether our current definition, diagnostic criteria, and characterization of patients with COPD is adequate to optimally care for this patient population. Blood eosinophils as a continuous variable in the treatment of COPD: impact on the guidelines. exacerbation leading to hospitalisation, the new 2019 and 2020 GOLD guidelines have fundamentally changed the patient gradation by taking into account only symptom burden and exacerbation history into consideration. In the past few years, there has been some jockeying in the placement of ICSs within the GOLD treatment paradigm. Patel AR, Patel AR, Singh S, Singh S, Khawaja I. This study demonstrates the utility of incorporating the 4 significant features of exposure, symptoms, CT scan characterization of emphysema and airway wall thickening and physiological measures of lung function. Antibiotics in COPD exacerbations •Cochrane review of 19 RCT’s •Primary outcomes •Treatment failure episodes •Secondary outcomes •Mortality, length of hospital stay, time to next exacerbation 0 10 20 30 40 50 60 70 Outpatient In-patient ICU Setting Setting 1. Outcomes were dichotomized for GOLD spirometry stage progression from Phase 1 to Phase 2. 2018;378(7):681-683. doi: https://doi.org/10.1056/NEJMc1715454, 24. Hopefully, they will find the work of the COPDGene® group compelling enough to incorporate their findings into an updated definition of COPD going forward. Wark, P. ACP Journal Club. This study also pointed out the benefits of smoking cessation leading to reduced progression for patients at early stages such as GOLD 0 and GOLD 1. DPI Dry powder inhaler . With this data set the authors use a matrix to identify 8 groups and define the relative probability of having COPD. endstream
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Home Oxygen in Chronic Obstructive Pulmonary Disease (expires May 15, 2020) How Do Dual Long-Acting Bronchodilators Prevent Exacerbations of Chronic Obstructive Pulmonary Disease? Indeed, there will certainly be overlap and insights to gain from the lung cancer screening program to date. Biomarker analysis demonstrated a significant association of the APD-only group with CRP, and sRAGE demonstrated greatest significance with both the EPD-only and the combined APD-EPD groups. Huprikar N. Dual bronchodilator therapy for chronic obstructive pulmonary disease: evidence for the efficacy and safety of fixed dose combination treatments in the setting of recent guideline updates. Chronic Obstr Pulm Dis. It will also be instructive to review how many lung cancers are serendipitously found on CT evaluations as part of COPDGene® and what are the characteristics of that cohort. Ann Intern Med. According to ATS 2020 guidelines, inhaled corticosteroids should only be used if a person also has asthma and/or a high eosinophil count, or experiences one or more COPD exacerbations each year. 2019;6(5):384-399. doi: http://dx.doi.org/10.15326/jcopdf.6.5.2019.0149. CXR Chest X-ray . 0
Our hospital's use of LAMA or LABA demonstrates the need to incorporate strategies to encourage appropriate prescribing of these LA inhalers per GOLD guidelines. 2020 report. N Engl J Med. Ann Intern Med. Four key disease characteristics - environmental exposure (cigarette smoking), clinical symptoms (dyspnea and/or chronic bronchitis), chest CT imaging abnormalities (emphysema, gas trapping and/or airway wall thickening), and abnormal spirometry - were evaluated in a group of 8784 current and former smokers who were participants in COPDGene® Phase 1. Analysis of chronic obstructive pulmonary disease exacerbations with the dual bronchodilator QVA149 compared with glycopyrronium and tiotropium (SPARK): a randomised, double-blind, parallel-group study. See the GINA 2020 report Box 4-2 for more information about the options for asthma action ... account local and national regulations and guidelines. Lancet Respir Med. 4 . 2018;23(1):12-13. doi: https://doi.org/10.1111/resp.13200, 21. 2001;46(8):798-825. �2j. Using these parameters to characterize these individuals it is apparent that many individuals, up to 40 %, fall into these categories and that they do indeed progress over 5 years with similar rates of mortality as those with an FEV1/FVC < 70%. (GOLD 2020) has some major and few minor changes to offer for the management of COPD. 2019;6(5):400-413. doi: http://dx.doi.org/10.15326/jcopdf.6.5.2019.0150, Posted in: Journal Club, Volume 7 | Issue 1. For Group C the initial recommendation would be a LAMA. Halpin DMG, Birk R, Brealey N, et al. of COPD (2020 Report), which aims to provide a non-biased review of the current evidence for the assessment, diagnosis and treatment of patients with COPD that can aid the clinician. Also sobering is the fact that the combined airway predominant disease group and emphysema predominant disease group individuals progressed at the highest 5-year all-cause mortality. There is also a new chart for the “Management of COPD” describing the important steps for “initial diagnosis, assessment and management” and then a separate iterative loop for the follow- up components of “Reviewing and Adjusting Therapy,” as well as a treatment paradigm for the role of dual combination therapy (LABAs, LAMAs and combinations with ICSs): ICS/LABA, LABA/LAMA, LABA/LAMA/ICS). For Group D the initiating therapy could be LAMA or LAMA/LABA if the patient is particularly symptomatic or ICS/LABA if the blood eosinophil count is greater than 300 cells/MCL. Am J Respir Crit Care Med. doi: https://doi.org/10.1183/23120541.00119-2017, 16. It has been appreciated that there are smokers with significant symptoms of cough, shortness of breath, and mucous production who may demonstrate evidence of emphysema and/or small airways disease, (noted by gas trapping and airway wall thickening), despite having normal FEV1 and a preserved FEV1/FVC ratio of greater than 70%. Criner GJ, Celli BR, Brightling CE, et al. Single-inhaler triple versus dual therapy in patients with COPD. 2018;4(2). COPD Foundation Of course, the big question that future studies will need to address is whether suggesting that a screening CT scan (with special quantitative measurement capabilities, as yet not standardized) on smokers with a certain smoking history (yet to be determined) leads to interventions that will provide significant positive outcomes that will justify the added expense to incorporate such screening. The study also highlights the need for such precision in understanding the underlying pathobiology as it is likely that targets for therapy will differ between those who have airway predominant disease only and those who have emphysema predominant disease only. In the initial iterations of the GOLD guidelines such patients were considered to be GOLD 0 but this Grade was dropped in subsequent iterations of the GOLD report. 84 0 obj
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