Initiation of Tx based on the GOLD ABCD assessment of Sx. and risk of exacerbation [Stable COPD]

The GOLD system은 증상 평가와 미래의 급성악화와 입원 위험에 근거하여 환자들을 구분합니다.

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Management of stable COPD: Initiation of therapy based on the GOLD ABCD assessment of symptoms and risk of exacerbation*

Groups	Symptoms	Risk	Suggested treatment
All			Avoidance of risk factor(s), such as smoking Annual influenza vaccination Pneumococcal vaccination Regular physical activity Regular review/correction of inhaler technique Long-term oxygen therapy if chronic hypoxemia Pulmonary rehabilitation
A	Less symptomatic Mild or infrequent symptoms (ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) [mMRC 0-1] ¶ or CAT <10Δ	Low risk 0 or 1 exacerbations in the past year without associated hospitalization	Short-acting bronchodilator (SABA, SAMA, or combination of SABA-SAMA), as needed.
B	More symptomatic Moderate to severe symptoms (ie, patient has to walk more slowly than others of same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness) [mMRC ≥2] ¶ or CAT ≥10Δ	Low risk 0 or 1 exacerbations in the past year without associated hospitalization	Regular treatment with a long-acting bronchodilator, either LAMA or LABA, based on patient preference. Short-acting bronchodilator (usually SABA) for symptom relief as needed.
C	Less symptomatic Mild or infrequent symptoms (ie, breathless with strenuous exercise or when hurrying on level ground or walking up a slight hill) [mMRC 0-1] ¶ or CAT <10Δ	High risk ≥2 exacerbations per year with one or more leading to hospitalization	Regular treatment with a LAMA; SABA available for symptom relief as needed.
D	More symptomatic Moderate to severe symptoms (ie, patient has to walk slower than others of same age due to breathlessness, has to stop to catch breath when walking on level ground at own pace, or has more severe breathlessness) [mMRC ≥2] ¶ or CAT ≥10Δ	High risk ≥2 exacerbations per year with one or more leading to hospitalization	Regular treatment with LAMA or, if severe breathlessness (eg, CAT >20), combination LABA plus LAMA. Combination glucocorticoid-LABA inhaler may be preferred, if features of asthma/COPD overlap. SABA available for symptom relief as needed.

Patients must be taught how and when to use their treatments, and treatment choices are adjusted based on patient responses. Medications being prescribed for other conditions should be reviewed. Refer to UpToDate topic on the diagnosis of COPD for further information about mMRC and CAT.

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COPD: chronic obstructive pulmonary disease; GOLD: Global Initiative for Chronic Obstructive Lung Disease; CAT: COPD Assessment Test; SABA: short-acting beta agonist; SAMA: short-acting muscarinic antagonist; LAMA: long-acting muscarinic antagonist (anticholinergic); LABA: long-acting beta agonist; mMRC: Modified Medical Research Council; FEV1: forced expiratory volume in one second; FVC: forced vital capacity.

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* All patients with COPD have a reduced FEV1/FVC ratio that is <0.70% predicted or <5th percentile lower limit of normal. The severity of airflow limitation is determined by the FEV1.

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¶ Symptom severity based on: Modified Medical Research Council (mMRC) Dyspnea scale.

Δ COPD Assessment Test (CAT): http://www.catestonline.org (Accessed on July 9, 2019).

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REF. UpToDate 2020.05.27