Summarizing the 2021 Updated GOLD Guidelines for COPD

All patients with COPD should be prescribed a short-acting bronchodilator for immediate relief. New findings regarding triple therapy suggest ... 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USPharm.2021;46(7):30-35.ABSTRACT:Chronicobstructivepulmonarydisease(COPD)isacomplexdiseasethatrequiresdifferentialdiagnosisandproperclassificationtoidentifyappropriatetherapy.Nonpharmacologictherapyandpreventativemeasuresshouldbeutilizedtopreventworseningofdisease,symptoms,andcomplications.TheGlobalInitiativeforChronicObstructiveLungDisease(GOLD)guidelinesclassifyapatient’sCOPDandproviderecommendationsforfirst-linetreatment.The2021updateincludedinformationregardingtheuseofe-cigarettesasnicotinereplacement,tripletherapy,andhowtheSARS-CoV-2virusimpactedpatientswithCOPD.Thisarticlewillfocusonthediagnosis,classification,andtreatmentofCOPD,aswellasrecentlyupdatedinformationregardingtheuseofe-cigarettesandtheimpactofCOVID-19.Chronicobstructivepulmonarydisease(COPD)isacommon,preventable,andtreatablediseasecharacterizedbypersistentrespiratorysymptomsandlimitationstoairflowduetoabnormalitieswithintheairwayand/oralveolar.CommonsymptomsofCOPDincludechronicorprogressivedyspnea,coughwithsputumproduction,andrecurrentlowerrespiratorytractinfections.ApatientmaybeatanincreasedriskforCOPDduetoexposuretonoxiousparticlesviacigarettesmoking,occupationalexposures,orairpollution,aswellasduetogenetics,socioeconomicstatus,airwayhyperreactivity,andotherfactors.PharmacologicandnonpharmacologictherapyforthemanagementofCOPDisusedtoreducethefrequencyandseverityofsymptomsandexacerbations,increaseexercisetolerance,andimproveoverallqualityoflife.SmokingcessationisimportantinpreventingprogressionofCOPDandisanareawherepharmacistscanassist.Apropertreatmentregimenisdeterminedbasedonseverityofairflowlimitation,symptomburden,andriskofexacerbation,asdefinedintheGOLDguidelines. TheSARS-CoV-2virushasposeduniqueobstaclestothediagnosisandmanagementofCOPD.ThismayincludedifficultiesdifferentiatingbetweenCOVID-19infectionandCOPD,increaseduseoftelemedicine,inabilitytoproperlyassessinhalertechnique,infectionrisksofusingcertaininhalertypes,andincreasedriskofseverecomplications.Thisreviewwillsummarizetheupdated2021GOLDguidelinesforthediagnosis,management,andpreventionofCOPD.1Diagnosis,Assessment,andClassificationCOPDisdiagnosedthroughacombinationofspirometryandmedicalhistory,includingsymptomhistoryandpresenceofriskfactors.Spirometryisanoninvasive,readilyavailable,objectivemeasureofairflowlimitation.SpirometryisrequiredtomakeanofficialdiagnosisofCOPDwithapostbronchodilatorforcedexpiratoryvolume/forcedvitalcapacity(FEV1/FVC)<0.70confirmingpersistentairflowlimitation.Keyriskfactorsincludesmokingstatusandoccupationalorenvironmentalexposures.CommonsymptomsofCOPDincludedyspnea,cough,sputumproduction,wheezing,andchesttightness.Whenassessingsymptoms,itisimportanttoconsiderdifferentialdiagnosis,especiallyduringtheCOVID-19pandemic,asnotedbytheupdatedGlobalInitiativeforChronicObstructiveLungDisease(GOLD)guidelines.The2021GOLDguidelinesrecommendthattheuseofspirometrybelimitedtoonlypatientswhorequireurgentoressentialtestingfordiagnosisand/ortoassesslungfunctionforinterventionalproceduresorsurgery,assuchtestingmayleadtoviraltransmission.Asaferalternativemaybetheuseofhomemeasurementofpeakexpiratoryvolumeandtheuseofvalidatedpatientquestionnaires.Thesequestionnairesarecompletedviaaninterviewtodeterminerespiratoryhealth,symptoms,comorbidities,andriskfactorsfordevelopingCOPD.2SymptomsofCOPDandCOVID-19infectionmayoverlap.Thetwomainoverlappingsymptomsarecoughandshortnessofbreath.SomeofthesymptomsthatfavorCOVID-19includefever,hypoxia,lossofsmellortaste,headaches,andlymphopenia.TheSARS-CoV-2virusmayalsocausepathophysiologicchangessuchasvascularinjury,pneumonitisassociatedwithhypoxemia,coagulopathy,highlevelsofsystemicinflammation,andmultiorganinvolvement.TheGOLDguidelinesclassifypatientsintofourdifferentcategories:GOLD1(mild),GOLD2(moderate),GOLD3(severe),orGOLD4(verysevere)basedontheirlevelofairflowlimitation.ThisisassessedbyevaluatingapostbronchodilatorFEV1/FVC.RefertoTABLE1formoreinformationregardingFEV1valuesandGOLDclassification.TheModifiedBritishMedicalResearchCouncil(mMRC)QuestionnaireandCOPDAssessmentTest(CAT)arethetwomostwidelyusedmeasurestoassesssymptomsofCOPD.ThemMRCisusedtoassessbreathlessnessofpatientswithCOPD.Itconsistsofgrades0to4,withgrade0indicatingbreathlessnessonlywithstrenuousexerciseandgrade4indicatingbreathlessnessthataffectsactivitiesofdailylivingaswellastheabilitytoleavethehouse.TheCATisaneight-itemmeasureofimpairmentexperiencedfromCOPD,withscoresrangingfrom0to40.HigherscoresontheCATindicatealargerimpactofCOPDonthepatient’slife.SymptomburdenandriskofexacerbationarealsofurtherclassifiedintoGOLDgroupsAthroughD,whichisusedtoguidetherapy.Classificationispatient-specific,andeachpatient’streatmentregimenshouldbetailoredspecificallytotheirneeds.RefertoFIGURE1fortheGOLDgroupclassificationalgorithm.NonpharmacologicandPreventativeTherapyNonpharmacologictherapyforCOPDincludessmokingcessation,physicalactivity,andvaccination.Smokingcessationisimportanttopreventdiseaseprogression.PatientswithCOPDwhoarecurrentsmokersshouldbeassessedforwillingnesstoquitsmokingandbeprovidedwitheducationonhowtoquit.Accordingtothe2021GOLDguidelines,counselingbyhealthcareprofessionals,evenforbriefperiodsoftime,significantlyincreasesquitratesoverself-initiatedstrategies.Therecommendedtreatmentforsmokingcessationisnicotine-replacementtherapy(NRT)withagentssuchasnicotinegum,inhalers,nasalspray,transdermalpatches,sublingualtablets,orlozenges.Otherpharmacologicagentssuchasvarenicline,bupropion,andnortriptylinehavebeenshowntoincreaselong-termquitrates,buttheseshouldonlybeusedaspartofasupportiveinterventionprogramratherthanmonotherapyforsmokingcessation.Theuseofe-cigarettesforsmokingcessationhasbeengainingpopularityoverrecentyears.Theseproductsprovideavaporizednicotinetobeinhaled.Whilee-cigaretteshavebeenavailableforover15years,thesafetyandefficacydataofe-cigarettesasasmokingcessationtoolarestilluncertain.Inadditiontonicotine,vapeproductsaremadewithchemicalssuchasvegetableglycine,flavoringagents,volatilecarbonyls,diacetyl,reactiveoxygenspecies,furones,metals,andothers.Severeacutelunginjury,eosinophilicpneumonia,alveolarhemorrhage,respiratorybronchiolitis,otherlungabnormalities,andevendeathhavebeenlinkedtoe-cigaretteuse.Onerandomized,controlledtrialbyBullenetalinvestigatedtheefficacyofe-cigarettescomparedwithnicotinepatchesinhelpingpeopletoquitsmoking.3Atotalof657participantswererandomizedina4:4:1ratioto16-mgnicotinee-cigarettes,21-mgonce-dailynicotinepatches,orplaceboe-cigarettes.Theprimaryoutcomemeasurewasbiochemicallyverifiedcontinuousabstinencefromsmokingafter6months.Atthis6-monthmark,7.3%participantsinthee-cigarettegrouphadverifiedabstinence,5.8%inthenicotinepatchgroup,and4.1%intheplacebogroup.However,therewasinsufficientstatisticalpowertoconcludethesuperiorityofnicotinee-cigarettesoverpatches.Anotherrandomized,controlledtrialbyHajeketalcomparedtheefficacyofe-cigarettestoNRTofthepatient’schoice.4Randomizationincluded446patientsintheNRTgroupand438inthee-cigarettegroup.Theprimaryoutcomemeasurewassustainedabstinenceratesat52weeks.TheNRTgrouphada1-yearquitrateof9.9%,whilethee-cigarettegrouphadarateof18%.TheseresultsweredeemedstatisticallysignificantwithP<.001.thistrialalsofoundthatparticipantsinthee-cigarettegroupshowedsignificantlybetteradherenceandexp eriencedfewerurgestosmokeintheinitial4weeksofquitting.duetopossiblerisksandalackoffurtherdata x september2022 inthisissue digitalmagazine archives subscription relatedce evidence-basedcareinimmunoglobulins:individualizingpatienttreatment pavingthewaytonoveltherapiesincll:realworldpatientcasesfortheoncologypharmacist viewmorece relatedcontent communityandspecialtypharmacyatacrossroads irritablebowelsyndromeinchildrenandadolescents pharmacotherapyupdatesforadultsoft-tissuesarcomas gettingthewordout advertisingcontacts editorialstaff professionalorganizations submittingamanuscript mediakit aboutus contactus privacypolicy donotsellmypersonalinformation careers classifieds copyright fullimage>