Sandra G. Adams, MD, MS
Pulmonary Diseases / Critical Care Medicine
University of Texas Health Science Center at San Antonio
South Texas Veterans Healthcare System
GOLD
Assessment
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
III: Severe
FEV1
30% to 49%
II: Moderate
FEV1
50% to 79%
I: Mild
FEV1 ≥80%
FEV1 = Forced expiratory volume in one second; FVC = Forced vital capacity
Global initiative for chronic obstructive lung disease. GOLD Website. http://www.goldcopd.com. Updated December 2011
Modified Medical Research Council
(MMRC) Dyspnea Scale
Grade Description of Breathlessness
0
I only get breathless with strenuous exercise
1
I get short of breath when hurrying on level ground or walking up a slight hill
2
On level ground, I walk slower than people of the same age because of
breathlessness, or have to stop for breath when walking at my own pace
3
I stop for breath after walking about 100 yards or after a few minutes on
level ground
4
I am too breathless to leave the house or I am breathless when dressing
Global initiative for chronic obstructive lung disease. GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
III: Severe
FEV1
30% to 49%
II: Moderate
FEV1
50% to 79%
I: Mild
FEV1 ≥80%
Modified Medical Research Council Dyspnea Score
0
1
2
3
More
severe
4
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
III: Severe
FEV1
30% to 49%
≥ 2 or more
per year
⌘See below
II: Moderate
FEV1
50% to 79%
1 per year
I: Mild
FEV1 ≥80%
Exacerbations
Frequent
exacerbations
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
None
Modified Medical Research Council Dyspnea Score
0
1
2
3
More
severe
4
Symptoms
⌘May
GOLD Website. http://www.goldcopd.com. Updated December 2011
consider “high risk” if develops 1 severe exacerbation or has been hospitalized for exacerbation (not part of GOLD report)
GOLD
Assessment
≥ 2 or more
per year⌘
III: Severe
FEV1
30% to 49%
II: Moderate
FEV1
50% to 79%
I: Mild
FEV1 ≥80%
A
1 per year
Mild-Mod Obstruction
Minimal Symptoms
Few Exacerbations
None
Modified Medical Research Council Dyspnea Score
0
1
2
3
Exacerbations
Frequent
exacerbations
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
More
severe
4
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
≥ 2 or more
per year⌘
III: Severe
FEV1
30% to 49%
A
II: Moderate
FEV1
50% to 79%
B
1 per year
Mild-Mod Obstruction Mild-Mod Obstruction
Severe Symptoms
Minimal Symptoms
Few Exacerbations
Few Exacerbations
I: Mild
FEV1 ≥80%
None
Modified Medical Research Council Dyspnea Score
0
1
2
3
Exacerbations
Frequent
exacerbations
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
More
severe
4
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
C
III: Severe
FEV1
30% to 49%
Severe Obstruction
Minimal Symptoms
++ Exacerbations
II: Moderate
FEV1
50% to 79%
A
Frequent
exacerbations
≥ 2 or more
per year⌘
B
1 per year
Mild-Mod Obstruction Mild-Mod Obstruction
Severe Symptoms
Minimal Symptoms
Few Exacerbations
Few Exacerbations
I: Mild
FEV1 ≥80%
None
Modified Medical Research Council Dyspnea Score
0
1
2
3
Exacerbations
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
More
severe
4
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
C
D
III: Severe
FEV1
30% to 49%
Severe Obstruction
Minimal Symptoms
++ Exacerbations
Severe Obstruction
Severe Symptoms
++ Exacerbations
II: Moderate
FEV1
50% to 79%
A
B
Frequent
exacerbations
≥ 2 or more
per year⌘
1 per year
Mild-Mod Obstruction Mild-Mod Obstruction
Severe Symptoms
Minimal Symptoms
Few Exacerbations
Few Exacerbations
I: Mild
FEV1 ≥80%
None
Modified Medical Research Council Dyspnea Score
0
1
2
3
Exacerbations
IV: Very Severe
FEV1 <30%
Post-bronchodilator
FEV1/FVC <70%
Severity of Obstruction
Worse
obstruction
More
severe
4
Symptoms
GOLD Website. http://www.goldcopd.com. Updated December 2011
GOLD
Assessment
C
D
Severe Obstruction
Minimal Symptoms
++ Exacerbations
Severe Obstruction
Severe Symptoms
++ Exacerbations
A
B
Mild-Mod Obstruction Mild-Mod Obstruction
Severe Symptoms
Minimal Symptoms
Few Exacerbations
Few Exacerbations
Symptoms
Frequent
exacerbations
Exacerbations
Severity of Airflow
Obstruction
Worse
obstruction
More
severe
GOLD Website. http://www.goldcopd.com. Updated December 2011
Management: GOLD Overview
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Active reduction of risk factors and administer vaccinations (influenza/pneumococcal)
Increase physical activity
Add short-acting bronchodilator (as needed)
Add one or more long-acting bronchodilator(s): scheduled
Add pulmonary rehabilitation
Consider adding inhaled corticosteroid***
Consider PDE4-inhibitor
PDE4-inhibitor = phosphodiesterase4 inhibitor
***Never use an inhaled corticosteroid as a single agent in patients with COPD
(inhaled corticosteroids are not approved by the FDA as a single agent for COPD
and they should always be prescribed with a long-acting bronchodilator)
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy: Overview
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
Long-acting bronchodilator(s): scheduled
Consider adding inhaled corticosteroid***
Consider PDE4-inhibitor
PDE4-inhibitor = phosphodiesterase4 inhibitor
***Never use an inhaled corticosteroid as a single agent in patients with COPD
(inhaled corticosteroids are not approved by the FDA as a single agent for COPD
and they should always be prescribed with a long-acting bronchodilator)
GOLD Website. http://www.goldcopd.com. Updated December 2011
First Choice Pharmacotherapy
A
B
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
SABA (prn)
ProAir®
Proventil®
Reli-On®
Ventolin®
Levalbuterol: Xopenex®
Pirbuterol:
Maxair®
Albuterol:
OR
Long-acting bronchodilator(s): scheduled
Consider adding inhaled corticosteroid
Consider PDE4-inhibitor
SABA = short-acting beta2-agonist
SAMA = short-acting muscarinic antagonist
(anticholinergic)
SAMA (prn)
Ipratropium:
Atrovent®
GOLD Website. http://www.goldcopd.com. Updated December 2011
First Choice Pharmacotherapy
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
Short-acting bronchodilator (prn)
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
Consider adding inhaled corticosteroid
LABA (scheduled)
Arformoterol: Brovana®
Formoterol:
Foradil®
Perforomist®
Indacaterol:
Arcapta®
Salmeterol: Serevent®
OR
Consider PDE4-inhibitor
LABA = long-acting beta2-agonist
LAMA = long-acting muscarinic antagonist
(anticholinergic)
LAMA (scheduled)
Tiotropium:
Spiriva®
GOLD Website. http://www.goldcopd.com. Updated December 2011
First Choice Pharmacotherapy
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
Short-acting bronchodilator (prn)
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
Consider adding inhaled corticosteroid
LABA or LAMA
(scheduled)
ICS/LABA*
ICS = inhaled corticosteroid
LABA = long-acting beta2-agonist
LAMA = long-acting muscarinic antagonist
(anticholinergic)
Consider PDE4-inhibitor
Budesonide/Formoterol
(Symbicort®)
Fluticasone/Salmeterol
(Advair®)
OR
LAMA
*Mometasone/Formoterol
(Dulera®) is another ICS/LABA
agent available in the US, but is
not yet FDA-approved for COPD
Tiotropium
(Spiriva®)
GOLD Website. http://www.goldcopd.com. Updated December 2011
First Choice Pharmacotherapy
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
Short-acting bronchodilator (prn)
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
Consider adding inhaled corticosteroid
LABA or LAMA
(scheduled)
ICS/LABA or LAMA
(scheduled)
Consider PDE4-inhibitor
ICS/LABA or LAMA
(scheduled)
ICS = inhaled corticosteroid
LABA = long-acting beta2-agonist
LAMA = long-acting muscarinic antagonist
(anticholinergic)
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (Second Choice)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Second choice:
SABA + SAMA
(scheduled)
or
LABA or LAMA
(scheduled)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
(scheduled)
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
First Choice:
(scheduled)
ICS/LABA or LAMA
(scheduled)
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (Second Choice)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
Second choice:
First Choice:
LABA + LAMA
ICS/LABA or LAMA
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (Second Choice)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
First Choice:
ICS/LABA or LAMA
Second choice:
LABA + LAMA
or
ICS + LAMA
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (Second Choice)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
First Choice:
ICS/LABA or LAMA
PDE4-inhibitor = phosphodiesterase4 inhibitor:
Roflumilast (Daliresp®)
Second choice:
ICS/LABA + LAMA
or
ICS/LABA + PDE4-inh
or
LAMA + PDE4-inh
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (1st & 2nd Choices)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Second choice:
SABA + SAMA
(scheduled)
or
LABA or LAMA
(scheduled)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
Second choice:
First Choice:
LABA + LAMA
ICS/LABA or LAMA
Second choice:
LABA + LAMA
or
ICS + LAMA
Second choice:
ICS/LABA + LAMA
or
ICS/LABA + PDE4-inh
or
LAMA + PDE4-inh
GOLD Website. http://www.goldcopd.com. Updated December 2011
Pharmacotherapy (Summary)
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Short-acting bronchodilator (prn)
First choice:
SABA or SAMA (prn)
Second choice:
SABA + SAMA
(scheduled)
or
LABA or LAMA
(scheduled)
Long-acting bronchodilator(s): scheduled
First choice:
Consider adding inhaled corticosteroid
LABA or LAMA
First choice:
Consider PDE4-inhibitor
ICS/LABA or LAMA
Second choice:
First Choice:
LABA + LAMA
ICS/LABA or LAMA
Second choice:
LABA + LAMA
or
ICS + LAMA
Consider Theophylline
Consider Theophylline
Consider PDE4-inh
or
Consider Theophylline
Second choice:
ICS/LABA + LAMA
or
ICS/LABA + PDE4-inh
or
LAMA + PDE4-inh
Consider Theophylline
GOLD Website. http://www.goldcopd.com. Updated December 2011
Non-pharmacological Management: GOLD
Overview
A
Stage: Mild-Moderate
Minimal Symptoms
Exacerbations (0-1/yr)
B
Stage: Mild-Moderate
Severe symptoms
Exacerbations (0-1/yr)
C
D
Stage: Severe-Very Severe Stage: Severe-Very Severe
Minimal Symptoms
Severe Symptoms
Exacerbations( ≥2/yr)
Exacerbations (≥2/yr)
Active reduction of risk factors
Administer vaccinations (influenza/pneumococcal)
Increase physical activity
Add pulmonary rehabilitation
Consider evaluation for need for supplemental oxygen
Consider surgical eval
GOLD Website. http://www.goldcopd.com. Updated December 2011