Global Initiative for Obstructive Lung Disease (GOLD) Criteria for COPD

Why Use

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.

When to Use

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.

Formula

Pearls / Pitfalls

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. Diagnosis of COPD requires a post-bronchodilator FEV₁/FVC of <0.7. 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, B, and E) explicitly guides therapeutic interventions for management of stable, baseline COPD. 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.

Management

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: Both a long-acting bronchodilator (LABA) and long-acting methacholine antagonist (LAMA) should be prescribed as initial therapy. If adherence is a concern, inhaler monotherapy may be considered. GOLD stage E: Initial treatment includes LAMA and LABA. An inhaled corticosteroid (ICS) should be considered for patients with elevated blood eosinophils (≥300). Patients with GOLD stage B or E disease and high symptom burden should be referred to and encouraged to participate in pulmonary rehabilitation.

Critical Actions

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).

Advice

Patients meeting spirometric criteria for airway 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 B or E, or patients with difficult-to-control symptoms or frequent COPD exacerbations.

More Information

Interpretation: GOLD Group Risk Pharmacologic Treatment Recommendation A Low risk, low exacerbation frequency, no hospitalizations, low symptom burden Bronchodilator B Low risk, low exacerbation frequency, no hospitalizations, increased symptom burden Long-acting bronchodilator (LABA) and long-acting methacholine antagonist (LAMA) E High risk, increased exacerbation frequency leading to hospitalization, variable symptom burden LAMA and LABA. ICS (inhaled corticosteroids) if blood eosinophils are ≥300