Improvements Proposed for the Updated GOLD Recommendations on COPD

COPD diagnosis stethoscope
Although the 2020 updates to the GOLD recommendations on COPD management have provided more clarity regarding treatment, additional recommendations on diagnostic tools are needed.

Although the 2020 updates to the Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations on chronic obstructive pulmonary disease (COPD) management have provided more clarity regarding treatment, a perspective article published in COPD suggests that additional recommendations on diagnostic tools are needed.

According to the authors, the GOLD spirometry criteria for prognosticating airflow obstruction and identifying health status are mainly focused on well-established disease in patients aged ≥50 years. The authors noted that further work-up is required “to observe the ideal interval for repeat spirometry, the duration for such follow-up, and strategies for interpretation.” In addition, the GOLD update continues to recommend a fixed ratio of forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) ratio of <0.7 for COPD diagnosis, which may potentially underdiagnose airflow obstruction in patients aged <50 years.

The authors also suggested that future updates to GOLD recommendations will depend on additional research that examines defining COPD with the lower limit of normal criteria, FEV1/FVC, and rapid FEV1 decline. Contrary to what is recommended by GOLD, replacing the modified Medical Research Council breathlessness scale with the COPD Assessment Test validated questionnaire may be more appropriate to assess severity of COPD. The authors also advised that future updates to the GOLD recommendations should include strategies to de-escalate inhaled corticosteroid therapy.

The authors noted that unlike other noncommunicable diseases such as hypertension and diabetes, an at-risk stage has not yet been identified for COPD (ie, “pre-COPD”). “Unfortunately, the earlier GOLD recommendations prematurely abandoned such an entity (GOLD stage 0) based on the evidence from the post-hoc analysis of the Copenhagen City Heart Study in which pre-COPD was based solely on the presence of single symptom of cough among smokers with normal FEV1/FVC ratio,” the authors wrote.

Future updates should include recommendations on using parameters of lung hyperinflation and exercise capacity to diagnose COPD. Further studies may also be needed on the guidance role of sputum eosinophils, which tend to be more effective than peripheral eosinophils in identifying severe COPD.

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The authors concluded that the current COPD diagnostic recommendations from GOLD “[appear] simplistic and can defeat the purpose of its own visionary goals.” They added that “[a]ny new opportunities to improve the care of one of the leading causes of global mortality should not be missed.”


Sakhamuri S, Seemungal T. COPD: Gaps in the GOLD recommendations and related imperative research needs [published online, January 6, 2020]. COPD. doi:10.1080/15412555.2019.1708297