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Journal ArticleDOI

Global Strategy for the Diagnosis, Management and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary

TL;DR: The assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation, and the concept of de‐escalation of therapy is introduced in the treatment assessment scheme.
Abstract: This Executive Summary of the Global Strategy for the Diagnosis, Management and Prevention of COPD, Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 Report focuses primarily on the revised and novel parts of the document. The most significant changes include: (i) the assessment of chronic obstructive pulmonary disease has been refined to separate the spirometric assessment from symptom evaluation. ABCD groups are now proposed to be derived exclusively from patient symptoms and their history of exacerbations; (ii) for each of the groups A to D, escalation strategies for pharmacological treatments are proposed; (iii) the concept of de-escalation of therapy is introduced in the treatment assessment scheme; (iv)non-pharmacological therapies are comprehensively presented and (v) the importance of co-morbid conditions in managing COPD is reviewed.
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Journal ArticleDOI
TL;DR: Blood eosinophils are recommended as a biomarker to support clinical decisions regarding the use of inhaled corticosteroids in chronic obstructive pulmonary disease patients, based on recent evidence from clinical trials.
Abstract: Precision medicine is a patient-specific approach that integrates all relevant clinical, genetic and biological information in order to optimise the therapeutic benefit relative to the possibility of side-effects for each individual. Recent clinical trials have shown that higher blood eosinophil counts are associated with a greater efficacy of inhaled corticosteroids (ICSs) in chronic obstructive pulmonary disease (COPD) patients. Blood eosinophil counts are a biomarker with potential to be used in clinical practice, to help target ICS treatment with more precision in COPD patients with a history of exacerbations despite appropriate bronchodilator treatment. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2017 pharmacological treatment algorithms, based on the ABCD assessment, can be applied relatively easily to treatment-naive individuals at initial presentation. However, their use is more problematic during follow-up in patients who are already on maintenance treatment. There is a need for a different system to guide COPD pharmacological management during follow-up. Recent large randomised controlled trials have provided important new information concerning the therapeutic effects of ICSs and long-acting bronchodilators on exacerbations. The new evidence regarding blood eosinophils and inhaled treatments, and the need to distinguish between initial and follow-up pharmacological management, led to changes in the GOLD pharmacological treatment recommendations. This article explains the evidence and rationale for the GOLD 2019 pharmacological treatment recommendations.

1,122 citations


Cites background or methods from "Global Strategy for the Diagnosis, ..."

  • ...categorization of patients at diagnosis(14)....

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  • ...recommendations for initial treatment and subsequent follow up for each group (14)....

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  • ...The Global initiative for the management of chronic Obstructive Lung Disease (GOLD) 2017 strategy document recommended that an assessment (ABCD grouping) based on symptoms and exacerbation risk should be performed after the initial diagnosis of COPD (14)....

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Journal ArticleDOI
TL;DR: The advantages of various drug delivery vehicles are discussed for better understanding of their utility in terms of current medical needs and the application of a wide range of nanomedicines is also described in the context of major chronic diseases.
Abstract: The application of nanomedicines is increasing rapidly with the promise of targeted and efficient drug delivery. Nanomedicines address the shortcomings of conventional therapy, as evidenced by several preclinical and clinical investigations indicating site-specific drug delivery, reduced side effects, and better treatment outcome. The development of suitable and biocompatible drug delivery vehicles is a prerequisite that has been successfully achieved by using simple and functionalized liposomes, nanoparticles, hydrogels, micelles, dendrimers, and mesoporous particles. A variety of drug delivery vehicles have been established for the targeted and controlled delivery of therapeutic agents in a wide range of chronic diseases, such as diabetes, cancer, atherosclerosis, myocardial ischemia, asthma, pulmonary tuberculosis, Parkinson’s disease, and Alzheimer’s disease. After successful outcomes in preclinical and clinical trials, many of these drugs have been marketed for human use, such as Abraxane®, Caelyx®, Mepact®, Myocet®, Emend®, and Rapamune®. Apart from drugs/compounds, novel therapeutic agents, such as peptides, nucleic acids (DNA and RNA), and genes have also shown potential to be used as nanomedicines for the treatment of several chronic ailments. However, a large number of extensive clinical trials are still needed to ensure the short-term and long-term effects of nanomedicines in humans. This review discusses the advantages of various drug delivery vehicles for better understanding of their utility in terms of current medical needs. Furthermore, the application of a wide range of nanomedicines is also described in the context of major chronic diseases.

295 citations


Cites methods from "Global Strategy for the Diagnosis, ..."

  • ...The current treatment strategy for COPD includes inhaled corticosteroids, anticholinergics, and β2-agonists, which have been primarily effective in controlling the symptoms but do not cure the underlying disease.(184) The major challenges in the nanotherapeutics of COPD are airway defense, mucus hypersecretion and severe inflammation....

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Journal ArticleDOI
01 Oct 2018
TL;DR: The salient features of the GOLD 2018 document are reviewed and commentary on features that merit further discussion are provided based on clinical experience and practice as well as literature review current as of February 2018.
Abstract: Global Strategy for the Diagnosis, Management, and Prevention of COPD 2018 is a consensus report published periodically since 2001 by an international panel of health professionals from respiratory medicine, socioeconomics, public health, and education comprising the Global Initiative for Chronic Obstructive Lung Disease (GOLD). The GOLD documents endeavor to incorporate latest evidence and expert consensus and are intended for use as "strategy documents" for implementation of effective care for chronic obstructive lung disease (COPD) on a global level. The GOLD 2018 report defines COPD as a "common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities, usually caused by significant exposure to noxious particles or gases," with the criteria of "persistent respiratory symptoms" being a new and controversial inclusion since 2017. With the availability of newer pharmacotherapy options, treatment recommendations are made on the basis of a review of the latest literature and directed by symptom burden and health care utilization. Apart from the change in definition, a major shift in the recommendations is the exclusion of severity of airflow limitation as one of the major factors in guiding therapy. We review the salient features of the GOLD 2018 document and provide commentary on features that merit further discussion based on our clinical experience and practice as well as literature review current as of February 2018.

292 citations


Cites background or methods from "Global Strategy for the Diagnosis, ..."

  • ...”(5,6) In the 2017 revision, GOLD had revised the definition of COPD to include “persistent respiratory symptoms” as an essential feature; however, the reasoning behind this has not been provided and the definition is carried through into the current version.(5,6) Chapter 1 addresses the global burden of COPD and cautions the reader about the expected increase in the prevalence and burden of COPD due to continued exposure to risk factors and aging of the world’s population....

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  • ...As with previous editions, the 2018 update(5) seeks to provide comprehensive evidence-based guidance for the diagnosis, management, and prevention of COPD.(5,6)...

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  • ...70, which “confirms the presence of persistent airflow limitation,” (2) “appropriate symptoms” including dyspnea, chronic cough, sputum production, or wheezing, and (3) “significant exposures to noxious stimuli” such as a history of smoking cigarettes, or other environmental exposures.(5,6) Most research studies of patients with COPD define a “significant exposure” to cigarettes as 10 pack-years; however, GOLD does not address quantification of smoking history....

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  • ...The bulk of COPD exacerbationsd80%dcan and should be successfully managed in the outpatient setting.(6) On-hand dual prescriptions for oral corticosteroids and antibiotics are a staple of successful COPD action plans....

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  • ...1490 historical use as an inclusion criterion for entry into clinical trials.(5,6) Screening spirometry is, appropriately, not recommended for asymptomatic patients, even those with risk factors....

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Journal ArticleDOI
TL;DR: The estimated overall prevalence of COPD in China in 2014–15 was 13·6%, indicating that this disease has become a major public-health problem.

248 citations

References
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Journal ArticleDOI
TL;DR: Screening with the use of low-dose CT reduces mortality from lung cancer, as compared with the radiography group, and the rate of death from any cause was reduced.
Abstract: Background The aggressive and heterogeneous nature of lung cancer has thwarted efforts to reduce mortality from this cancer through the use of screening. The advent of low-dose helical computed tomography (CT) altered the landscape of lung-cancer screening, with studies indicating that low-dose CT detects many tumors at early stages. The National Lung Screening Trial (NLST) was conducted to determine whether screening with low-dose CT could reduce mortality from lung cancer. Methods From August 2002 through April 2004, we enrolled 53,454 persons at high risk for lung cancer at 33 U.S. medical centers. Participants were randomly assigned to undergo three annual screenings with either low-dose CT (26,722 participants) or single-view posteroanterior chest radiography (26,732). Data were collected on cases of lung cancer and deaths from lung cancer that occurred through December 31, 2009. Results The rate of adherence to screening was more than 90%. The rate of positive screening tests was 24.2% with low-dose CT and 6.9% with radiography over all three rounds. A total of 96.4% of the positive screening results in the low-dose CT group and 94.5% in the radiography group were false positive results. The incidence of lung cancer was 645 cases per 100,000 person-years (1060 cancers) in the low-dose CT group, as compared with 572 cases per 100,000 person-years (941 cancers) in the radiography group (rate ratio, 1.13; 95% confidence interval [CI], 1.03 to 1.23). There were 247 deaths from lung cancer per 100,000 person-years in the low-dose CT group and 309 deaths per 100,000 person-years in the radiography group, representing a relative reduction in mortality from lung cancer with low-dose CT screening of 20.0% (95% CI, 6.8 to 26.7; P=0.004). The rate of death from any cause was reduced in the low-dose CT group, as compared with the radiography group, by 6.7% (95% CI, 1.2 to 13.6; P=0.02). Conclusions Screening with the use of low-dose CT reduces mortality from lung cancer. (Funded by the National Cancer Institute; National Lung Screening Trial ClinicalTrials.gov number, NCT00047385.).

7,710 citations


"Global Strategy for the Diagnosis, ..." refers background in this paper

  • ...Two studies of low-dose chest computed tomography (LDCT) screening report improved survival in subjects aged 55-74 years, current smokers or those who quit within the previous 15 years, with a smoking history of at least 30 packyears.(337,338) LDCT is now recommended in the U....

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Journal ArticleDOI
TL;DR: The main goals of the updated document are to improve the quality of care provided to patients with COPD and to develop the project using a disease-oriented approach.
Abstract: The Standards for the Diagnosis and Treatment of Patients with COPD document 2004 updates the position papers on chronic obstructive pulmonary disease (COPD) published by the American Thoracic Society (ATS) and the European Respiratory Society (ERS) in 1995 1, 2. Both societies felt the need to update the previous documents due to the following. 1) The prevalence and overall importance of COPD as a health problem is increasing. 2) There have been enough advances in the field to require an update, especially adapted to the particular needs of the ATS/ERS constituency. 3) It allows for the creation of a “live” modular document based on the web; it should provide healthcare professionals and patients with a user friendly and reliable authoritative source of information. 4) The care of COPD should be comprehensive, is often multidisciplinary and rapidly changing. 5) Both the ATS and the ERS acknowledge the recent dissemination of the Global Initiative of Obstructive Lung Disease (GOLD) 3 as a major worldwide contribution to the battle against COPD. However, some specific requirements of the members of both societies require adaptation of the broad GOLD initiative. Those requirements include specific recommendations on oxygen therapy, pulmonary rehabilitation, noninvasive ventilation, surgery in and for COPD, sleep, air travel, and end-of-life. In addition, special emphasis has been placed on issues related to the habit of smoking and its control. ### Goals and objectives The main goals of the updated document are to improve the quality of care provided to patients with COPD and to develop the project using a disease-oriented approach. To achieve these goals, both organisations have developed a modular electronic web-based document with two components. 1) A component for health professionals that intends to: raise awareness of COPD; inform on the latest advances in the overall pathogenesis, diagnosis, monitoring and management of COPD; and …

4,312 citations


"Global Strategy for the Diagnosis, ..." refers background in this paper

  • ...Short-acting inhaled beta2-agonists, with or without short-acting anticholinergics, are the initial bronchodilators recommended for acute treatment of exacerbations.(258,259) There are no significant differences in FEV1 when using metered dose inhalers (MDI) (with or without a spacer device) or nebulizers to deliver the agent,(260) although the latter may be an easier delivery method for sicker patients....

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Journal ArticleDOI
TL;DR: The BODE index, a simple multidimensional grading system, is better than the FEV1 at predicting the risk of death from any cause and from respiratory causes among patients with COPD.
Abstract: background Chronic obstructive pulmonary disease (COPD) is characterized by an incompletely reversible limitation in airflow. A physiological variable — the forced expiratory volume in one second (FEV 1 ) — is often used to grade the severity of COPD. However, patients with COPD have systemic manifestations that are not reflected by the FEV 1 . We hypothesized that a multidimensional grading system that assessed the respiratory and systemic expressions of COPD would better categorize and predict outcome in these patients. methods We first evaluated 207 patients and found that four factors predicted the risk of death in this cohort: the body-mass index (B), the degree of airflow obstruction (O) and dyspnea (D), and exercise capacity (E), measured by the six-minute–walk test. We used these variables to construct the BODE index, a multidimensional 10-point scale in which higher scores indicate a higher risk of death. We then prospectively validated the index in a cohort of 625 patients, with death from any cause and from respiratory causes as the outcome variables. results There were 25 deaths among the first 207 patients and 162 deaths (26 percent) in the validation cohort. Sixty-one percent of the deaths in the validation cohort were due to respiratory insufficiency, 14 percent to myocardial infarction, 12 percent to lung cancer, and 13 percent to other causes. Patients with higher BODE scores were at higher risk for death; the hazard ratio for death from any cause per one-point increase in the BODE score was 1.34 (95 percent confidence interval, 1.26 to 1.42; P<0.001), and the hazard ratio for death from respiratory causes was 1.62 (95 percent confidence interval, 1.48 to 1.77; P<0.001). The C statistic for the ability of the BODE index to predict the risk of death was larger than that for the FEV 1 (0.74 vs. 0.65).

3,688 citations


"Global Strategy for the Diagnosis, ..." refers methods in this paper

  • ...The BODE (Body mass index, Obstruction, Dyspnea, and Exercise) method gives a composite score that is a better predictor of subsequent survival than any single component.(71) Simpler alternatives that do not include exercise testing need validation to confirm suitability for routine clinical use....

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Journal ArticleDOI
TL;DR: The reduction in death from all causes among patients with COPD in the combination-therapy group did not reach the predetermined level of statistical significance, and there were significant benefits in all other outcomes among these patients.
Abstract: We conducted a randomized, double-blind trial comparing salmeterol at a dose of 50 μg plus fluticasone propionate at a dose of 500 μg twice daily (combination regimen), administered with a single inhaler, with placebo, salmeterol alone, or fluticasone propionate alone for a period of 3 years. The primary outcome was death from any cause for the comparison between the combination regimen and placebo; the frequency of exacerbations, health status, and spirometric values were also assessed. Results Of 6112 patients in the efficacy population, 875 died within 3 years after the start of the study treatment. All-cause mortality rates were 12.6% in the combinationtherapy group, 15.2% in the placebo group, 13.5% in the salmeterol group, and 16.0% in the fluticasone group. The hazard ratio for death in the combination-therapy group, as compared with the placebo group, was 0.825 (95% confidence interval [CI], 0.681 to 1.002; P = 0.052, adjusted for the interim analyses), corresponding to a difference of 2.6 percentage points or a reduction in the risk of death of 17.5%. The mortality rate for salmeterol alone or fluticasone propionate alone did not differ significantly from that for placebo. As compared with placebo, the combination regimen reduced the annual rate of exacerbations from 1.13 to 0.85 and improved health status and spirometric values (P<0.001 for all comparisons with placebo). There was no difference in the incidence of ocular or bone side effects. The probability of having pneumonia reported as an adverse event was higher among patients receiving medications containing fluticasone propionate (19.6% in the combination-therapy group and 18.3% in the fluticasone group) than in the placebo group (12.3%, P<0.001 for comparisons between these treatments and placebo). Conclusions The reduction in death from all causes among patients with COPD in the combinationtherapy group did not reach the predetermined level of statistical significance. There were significant benefits in all other outcomes among these patients. (ClinicalTrials.gov number, NCT00268216.)

3,037 citations

Journal ArticleDOI
TL;DR: The St. George's Respiratory Questionnaire is a valid measure of impaired health in diseases of chronic airflow limitation that is repeatable and sensitive andMultivariate analysis demonstrated that SGRQ scores summed a number of areas of disease activity.
Abstract: A need was identified for a fixed-format self-complete questionnaire for measuring health in chronic airflow limitation. A 76-item questionnaire was developed, the St. George's Respiratory Questionnaire (SGRQ). Three component scores were calculated: symptoms, activity, and impacts (on daily life), and a total score. Three studies were performed. (1) Repeatability was tested over 2 wk in 40 stable asthmatic patients and 20 patients with stable COPD. The coefficient of variation for the SGRQ total score was 19%. (2) SGRQ scores were compared with spirometry, 6-min walking distance (6-MWD), MRC respiratory symptoms questionnaire, anxiety, depression, and general health measured using the Sickness Impact Profile score. A total of 141 patients were studied, mean age 63 yr (range 31 to 75) and prebronchodilator FEV1, 47% (range 11 to 114%). SGRQ scores correlated with appropriate comparison measures. For example, symptom score versus frequency of wheeze, r2 = 0.32, p less than 0.0001; activity versus 6-MWD, r2 = 0.50, p less than 0.0001; impact versus anxiety, r2 = 0.38, p less than 0.0001. Multivariate analysis demonstrated that SGRQ scores summed a number of areas of disease activity. (3) Changes in SGRQ scores and other measures were studied over 1 yr in 133 patients. Significant correlations were found between changes in SGRQ scores and the comparison measures (minimum r2 greater than 0.05, p less than 0.01). Multivariate analysis showed that change in total SGRQ score summed changes in a number of aspects of disease activity. We conclude that the SGRQ is a valid measure of impaired health in diseases of chronic airflow limitation that is repeatable and sensitive.

2,835 citations

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