Global Initiative for Obstructive Lung Disease (GOLD) Criteria for COPD
Use in patients >18 years of age with already-diagnosed COPD by spirometry (FEV₁/FVC <0.7) with baseline symptoms and lung function. Do not use to diagnose COPD and do not use in patients with acute exacerbation.
- Patients with COPD with recent spirometry results available in the ambulatory setting who are at their baseline with regard to symptoms and lung function.
- Do not use in patients suffering an acute exacerbation or worsening of respiratory symptoms.
- The GOLD Criteria were developed and primarily validated for patients >18 years of age.
- The GOLD Criteria are used clinically to determine the severity of expiratory airflow obstruction for patients with COPD.
- Should not be used to diagnose COPD, but rather to categorize clinical severity to inform prognosis and to guide therapeutic interventions.
- Determining a patient’s GOLD status requires a multidimensional assessment of a patient’s spirometry, symptom burden, and frequency of COPD exacerbations.
- Spirometry is measured by formal pulmonary function testing, and the percent predicted of the forced expiratory volume in 1 second (FEV₁) is the value used in calculating a patient’s GOLD status.
- Symptom burden is quantified by either the modified Medical Research Council (mMRC) Dyspnea Scale or COPD assessment test (CAT) score.
- Exacerbation frequency encompasses the number of acute symptomatic deteriorations of COPD over the past 12 months requiring either increased medical management or hospitalization.
- GOLD status (A-D) explicitly guides therapeutic interventions for management of stable, baseline COPD, with GOLD A patients requiring less medical management than GOLD D patients.
- The 2017 GOLD Criteria predict mortality risk for patients with COPD, but not more accurately than the earlier GOLD scores (Leivseth and Soriano).
- Stage B may predict higher mortality than stage C COPD, as determined by the 2011 GOLD Criteria (Lange).
- GOLD status in the 2011 criteria does predict risk of exacerbation better than the older, spirometrically-based GOLD Criteria (Lange and Soriano).
- GOLD stages B, C, and D do not accurately reflect patient’s functional status as measured by 6 minute walk testing, London Chest Activities of Daily Living Scale, or daily life activity monitoring (Moreira).
- The therapeutic guidance coupled to GOLD stages is primarily based on expert consensus rather than direct evidence supporting specific therapeutic recommendations for a given GOLD stage; however, the individual medications and clinical interventions are supported by relatively strong level of evidence.
- Predicts risk of future COPD exacerbations (Lange and Soriano) and mortality (Lange, Leivseth, and Soriano).
- Can serve as a framework to discuss disease management and risk reduction for patients with COPD.
- GOLD stages are linked to specific therapeutic recommendations for medical management for both chronic COPD, as well as suggestions for acute exacerbations.
- Derived from and described in a global patient population, implying relevancy for use in a wide variety of clinical and geographic settings.
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- When clinically appropriate, patients with respiratory symptoms and risk factors for COPD should undergo spirometry to determine FEV₁ and FEV₁/FVC.
- Patients meeting spirometric criteria for airways obstruction and clinical criteria for COPD should have their GOLD status determined.
- Non-pharmacologic and pharmacologic treatments based on a patient’s GOLD stage should be considered and initiated as clinically appropriate (see Management below).
- Referral to a pulmonologist should be considered for patients whose COPD is GOLD stage C or D, or patients with difficult-to-control symptoms or frequent COPD exacerbations regardless of GOLD stage.
- Regardless of their GOLD stage, all patients with COPD should be counseled regarding risk reduction:
- Education about the nature, prognosis, and outcomes of COPD should be emphasized in initial and subsequent patient visits.
- Discussion of and recommendations about behavioral risk factors must be performed, including (primarily) smoking cessation and avoidance of secondhand smoke.
- Avoidance of indoor and outdoor air pollution (including biomass fuel in appropriate settings), a potential trigger for a COPD exacerbation, should be emphasized.
- Age- and clinically-appropriate vaccinations should be provided.
- Next steps in therapeutic management are guided by the GOLD stage:
- GOLD stage A: A bronchodilator should be offered (long- or short-acting as clinically indicated.) This medication should be continued if there is symptomatic response.
- GOLD stage B: A long-acting bronchodilator (either a long-acting bronchodilator [LABA] or long-acting methacholine antagonist [LAMA]) should be prescribed as initial therapy.
- GOLD stage C: LAMA is appropriate initial management for a patient with GOLD stage C disease, although patients with stage C disease and a history of frequent exacerbations may benefit from LAMA + LABA or LABA + ICS (inhaled corticosteroids) combination therapy for initial management.
- GOLD stage D: Initial treatment with combined LAMA and LABA therapy is indicated for GOLD stage D, with consideration of adding of an inhaled corticosteroid (ICS) for patients with frequent exacerbations.
- Patients with GOLD stage B, C, or D disease and high symptom burden should be referred to and encouraged to participate in pulmonary rehabilitation.
- GOLD Criteria cannot be used to assess disease severity in patients without a measured recent FEV₁.
- Treatment interventions initiated based on GOLD stage must always be considered in the context of an individual patient’s response, and medications should be adjusted accordingly.
- Patient education about the risk of airways obstruction and COPD should be emphasized for former and current smokers, regardless of spirometry results or GOLD stage, and smoking cessation encouraged.
- The GOLD Criteria do not capture or characterize former and current smokers who do not meet spirometric criteria for COPD (defined as FEV₁/FVC <0.70), as these patients are still at increased risk of respiratory symptoms (Woodruff).
- Jeremy B. Richards, MD