Dr. Anzueto: Certainly; the new GOLD recommendations for COPD have clearly changed in the way we evaluate these patients. And I would recommend to take into consideration not only disease severity assessed by lung function, but also patient symptoms and history of exacerbations.
The initial GOLD document published almost 10 years ago was using lung function (FEV1) to stage the severity of the disease, but this approach only captures one component of COPD severity. A significant percentage of patients have preserved lung function—they are in the moderate range, FEV1s around 60%—[but] they also are symptomatic. If we only assess COPD by spirometry, we will miss this large number of patients. The current spirometric criteria for airflow limitation remain the post-bronchodilator FEV1 and the fixed ratio of FEV1/FVC <70%. And we should emphasize the need to do a spirometry to diagnose this condition. Other aspects of the disease, like severity of symptoms, risk of hospitalizations, and presence of comorbid conditions are very important and are taken into consideration in the new staging system.1
We are now viewing the COPD in a more global way. The fact that we take symptoms that may have impact [on] the patient's quality of life into consideration, and also future events like exacerbations, is going to change the approach to our patients; and the objective is to improve the quality of life and their overall performance. This implies that in our practice, we have to change the way to assess our patients.
First, symptoms cannot be assessed just [by] asking the patients; so it's recommended to use objective tools like the CAT—or the COPD assessment test—the dyspnea scale, the Medical Research Council [MRC] Questionnaire, [or] any tools that you want to use as a healthcare provider to get an objective assessment of how the patient's symptoms are limiting his or her function. 2-5
And then we need to ask our patients about exacerbations and hospitalizations in order to understand that the exacerbations they may have are not day-to-day variations in their symptoms. We now know that having frequent exacerbations, especially the history of previous events, are predictors of future events, so it's very important to identify the patients who are having exacerbations that put them at risk to require hospitalizations.1
So in the new GOLD system, patients are going to be divided—taking into consideration all these factors—in[to] four categories:
- Category A. Those are low-risk patients, less symptomatic. We used to name them the GOLD 1 or [GOLD] 2 (mild to moderate airflow limitation). They have 0 to 1 exacerbation per year, and their [m]MRC score is 0 to 1 or their CAT score is <10.
- But patients in Category B, although have the same low risk and fall in the same category on spirometry, these patients have higher scores in the mMRC, >2, or the CAT score is >10.
- Category C [patients] are high-risk patients that have less symptoms. These are going to be the GOLD 3 and [GOLD] 4, [with] severe and very severe airflow limitation. They're having >2 exacerbations a year or >1 hospitalization, but their [m]MRC grade [is] still low, 0-1 or the CAT score is <10.
- While [patients] in the Category D, they are going to be high risk. They're having frequent exacerbations and hospitalizations, but they are also more symptomatic.
So you can appreciate if we put all these elements together, we will [be] able to identify a group of patients that have more or less severe disease and to customize the therapy based on their needs.