Temporal transitions in COPD severity stages within the GOLD 2017 classification system

Prediction of Hospitalization and Mortality in Patients with Chronic Obstructive Pulmonary Disease with the New Global Initiative for Chronic Obstructive Lung Disease 2023 Group Classification: A Prospective Cohort and a Retrospective Analysis

Background

The revised Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 group ABE classification has undergone major modifications, which can simplify clinical assessment and optimize treatment recommendations for Chronic Obstructive Pulmonary Disease (COPD). However, the predictive value of the new grouping classification for prognosis is worth further exploration. We aimed to compare the prediction of hospitalization and mortality between this new GOLD group 2023 ABE classification and the earlier 2017 ABCD classification in a Chinese COPD cohort.

Methods

Data from 2,499 outpatients with COPD, who first registered in the RealDTC study of Second Xiangya Hospital from December 2016 to December 2019, were collected prospectively and assessed retrospectively. Patients were followed up on all-cause mortality until October 2022 or death.

Results

Of the 2,499 patients with COPD, the risk of hospitalization during the first-year follow-up was higher in group E than in groups A and B. The mortality was higher in group E than in groups A and B, and group B was higher than group A. No differences were seen in the area under the curve (AUC) of 2017 vs 2023 GOLD grouping to predict hospitalization. The time-dependent AUC and concordance index for predicting mortality is slightly higher in the GOLD 2017 ABCD than in the 2023 ABE groups. The new GOLD 12-subgroup (1A-4E) classification combining the GOLD 1-4 staging and grouping performed similarly discriminate predictive power for mortality to the GOLD 2017 16-subgroup (A1-4D) classification.

Conclusion

The risk of hospitalization during the first-year follow-up was higher in group E than in groups A and B. The all-cause mortality increased gradually from GOLD group A to E. The GOLD 2023 classification based on ABE groups did not predict mortality better than the earlier 2017 ABCD classifications.

The future exacerbation and mortality of different inhalation therapies among patients with chronic obstructive pulmonary disease in various GOLD groups: a focus on the GOLD 2017 and GOLD 2023 reports

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2023 report revised the combined assessment, merged the C and D groups into the E group, and revised the initial inhalation therapy recommendation.

OBJECTIVES

This study aimed to analyze the future exacerbation and mortality of different inhalation therapies among patients with chronic obstructive pulmonary disease (COPD) in various groups based on the GOLD 2017 and GOLD 2023 reports.

DESIGN

This is a multicenter and retrospective study.

METHODS

Stable COPD patients from the database setup by 12 hospitals were enrolled. The patients were divided into Groups A, B, C, D, and E according to the GOLD 2017 and GOLD 2023 reports. Then, the patients were classified into long-acting muscarinic antagonist (LAMA), long-acting β2-agonist (LABA) + inhaled corticosteroid (ICS), LABA + LAMA, and LABA + LAMA + ICS subgroups. Data on exacerbation and death during 1 year of follow-up were collected.

RESULTS

A total of 4623 patients were classified into Group A (15.0%), Group B (37.8%), Group C (7.3%), Group D (39.9%), and Group E (47.2%). The exacerbation, frequent exacerbation, and mortality showed no differences between different inhalation therapies in Groups A and C. Patients treated with LABA + LAMA or LABA + LAMA + ICS had a lower incidence of exacerbation and frequent exacerbation than patients treated with LAMA or LABA + ICS in Groups B, D, and E. The exacerbation, frequent exacerbation, and mortality showed no differences between different inhalation therapies after combining Groups A with C.

CONCLUSION

Patients in Group A should be recommended to undergo mono-LAMA, while patients in Groups B and E should be recommended treatment with LABA + LAMA, which is consistent with the GOLD 2023 report. However, it is worth considering merging Groups A and C into a single group and recommending mono-LAMA as the initial inhalation therapy.

Experience on the Management of Patients with Asthma or Chronic Obstructive Pulmonary Disease During the COVID-19 Pandemic: the NEUMOBIAL Study

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) and asthma are treatable but greatly underdiagnosed disorders. Telemedicine made it possible to continue diagnosis, follow-up visits and treatment modifications during the COVID-19 pandemic. The present study describes the management of patients with COPD and asthma, and their treatments during the pandemic from the pulmonologist's perspective.

METHODS

NEUMOBIAL was an ecological study with aggregated data. A total of 279 Spanish pulmonologists answered a 60-question survey about their last 10 patients, focused on the characterisation and changes in visits and treatments during the pandemic.

RESULTS

Most pulmonologists (72.0%) considered that the pandemic negatively altered the diagnosis and follow-up of patients with asthma or COPD. Diagnostic tests were reduced during the pandemic, mainly because they were not recommended by pulmonologists (68.1% and 72.7% in the case of COPD and asthma tests, respectively). Moreover, 17.3% of the COPD and 19.1% of the asthma visits were remote visits. According to pulmonologists, low adherence to treatment was mainly due to a lack of patient knowledge about their disease (75.3% and 81.7% in COPD and asthma, respectively). Other factors that also influenced adherence were inadequate use of the inhaler (59.5% for COPD and 57.7% for asthma) and a lack of knowledge about the device (57.3% for COPD and 57.7% for asthma). Pulmonologists chose Zonda^® for COPD because of the ease of use of the device (73.1%) and the ability to check whether the entire dose was inhaled (69.5%). For asthma, Spiromax^® was chosen because of the ease of use of the device (85.7%) and the possibility of using a single device for maintenance and reliever treatment (82.4%).

CONCLUSION

According to pulmonologists, during the pandemic, treatments for COPD and asthma were mainly chosen on the basis of their ease of use; treatment adherence was good; and the number of remote visits increased.

No Independent Influence of Statins on the Chronic Obstructive Pulmonary Disease Exacerbation Rate: A Cohort Observation Study Over 10 Years

Purpose

Some previously published primarily retrospective studies have shown that statins could reduce the rate and severity of exacerbations, the length of hospital stays, and mortality in patients with chronic obstructive pulmonary disease (COPD), but retrospective data needs to be reviewed regarding this connection since statins are cholesterol-lowering drugs. Therefore, the aim of this study was to investigate the independent influence of statins on the exacerbation rate in COPD patients.

Methods

An observational retrospective study was conducted to assess the independent influence of statins on the COPD exacerbation rate at the Department of Internal Medicine, Pulmonary Division, Internal Intensive Care Medicine, Infectiology, and Sleep Medicine, Märkische Clinics Health Holding Ltd, Clinic Lüdenscheid, Witten/Herdecke University from January 1, 2010 to December 31, 2020. This study enrolled patients with COPD in 2010 and documented their exacerbation rate over a further 10 years. The number of exacerbations in COPD patients was compared between statin users and non-users.

Results

Of the total of 295 [176 male (59.7%)] COPD patients, 105 (35.6%, CI 30.3–41.2%) patients with COPD were treated with statins, and 190 (64.4%, CI 58.8–69.7%) were treated without statins. The mean exacerbation rate in the COPD patients who received statin did not differ from that in the COPD patients who did not receive statin (p = 0.175). Also, the mortality rates did not differ between the statin-treated and non-statin-treated COPD patients (p = 0.271).

Conclusion

Statins have no effect on the exacerbation rate or mortality in COPD patients.

Transitions between COPD groups: A cross-sectional study in Turkey

INTRODUCTION

Since GOLD 2017 separates spirometry results from 'ABCD' groups, there have been some changes to the stages of COPD patients. Our aim was to investigate the shifts in COPD groups after GOLD 2017.

METHODS

COPD patients from outpatient clinics of 3 hospitals in Turkey were stratified into old and new ABCD groups according to exacerbation history, mMRC evaluation and spirometry results for both GOLD 2011 and 2017 assessments. Treatment protocols were also evaluated if they were suitable for both classifications.

RESULTS

There were 578 patients (334 men, 244 women) with a mean age of 65.21±10.42. The distribution of patients from group A to D was 28%, 15%, 15%, 42% (GOLD 2011) and 36%, 22%, 7% and 35% (GOLD 2017) respectively. There were shifts from group C to A (53.4%) and D to B (18.4%). The treatment suitability was 66.3% in GOLD 2011 and 60.9% in GOLD 2017. The most common inappropriate treatment protocol was triple therapy. Presence of exacerbations in last year, mMRC score, FEV1 level (p < 0.01 for three parameters) and proportion of males (p = 0.029) were statistically significantly higher in groups C and D of GOLD 2017 compared with new patients in group A and B of GOLD 2017 (shifted from GOLD 2011's C-D groups).

CONCLUSION

There were shifts from group C to A and D to B with GOLD 2017, which means some high-risk COPD patients were reclassified into low-risk groups. Despite guideline updates, there are still many COPD patients with overtreatment. To our knowledge, this is the first study examining transitions between COPD groups after GOLD 2017 in Turkey.

Protective effect of Alpinetin on rats with chronic obstructive pulmonary disease

To investigate the function and mechanism of Alpinetin on chronic obstructive pulmonary disease (COPD) in rat model. The markers of lung injury (body weight/pulmonary function) were measured, and the protein levels of inflammatory-, apoptosis-, and fibrotic-related were determined by Western blot. HE/TUNEL/Masson staining was performed to investigate the mechanisms involved. The levels of inflammatory factors lung injury were detected by ELISA. The in vivo activities of all molecules were determined using a rat model. Alpinetin suppressed the injury of alveolus pulmonis cells occurred in vivo due to the decrease in inflammatory factors and biochemical markers by reduced the expression of TGF-β1, α-SMA, and TNF-α (p < .05), associated with the declined of Caspase-3 and Caspase-9 (p < .01). Additionally, protective affection of Alpinetin downregulated the IL-6 and upregulated the IL-10 (p < .01). Protective affection of Alpinetin inhibits the apoptosis, inflammation, and fibrosis of alveolus pulmonis cells in rat models.

2011 GOLD Stages of COPD: Transitions, Predictor Factors and Comparison with 2017 GOLD Stages

Background

Despite wide use of the Global Initiative for Chronic Obstructive Pulmonary Disease (GOLD) 2011, little is known about between-stage transitions and what factors predict worsening transitions in patients with chronic obstructive pulmonary disease (COPD).

Objective

To investigate the transition frequency between GOLD 2011 stages among patients with stable COPD over a 2-year follow-up, to identify potential non-pulmonary predictor factors for worsening transitions, and to compare transition frequencies between GOLD 2011 stages and the new GOLD 2017 stages.

Patients and Methods

We prospectively included 137 patients with stable COPD (mean age, 66.9 ± 8.3 years). GOLD 2011 and GOLD 2017 stages were measured at baseline, 1-year follow-up, and 2-year follow-up. To evaluate non-pulmonary variables as potential predictors of worsening transitions, we used regression models adjusted for sociodemographic, clinical, and pulmonary variables using generalized estimating equations.

Results

The study period included 246 opportunities for transition, and 39 worsening transitions occurred within GOLD 2011 stages. Predictors of worsening transitions included BODE index (OR, 1.20; 95% CI, 1.00–1.44), quadriceps strength (OR, 0.87; 95% CI, 0.76–0.99), and limited mobility activities (OR, 1.02; 95% CI, 1.00–1.05). The frequency of worsening transitions for stages B and C differed between GOLD 2011 and GOLD 2017. Stages A and D were the most stable in both classifications.

Conclusion

Non-pulmonary factors predicted worsening transitions among the GOLD 2011 stages of COPD severity. The choice of GOLD 2011 versus GOLD 2017 may influence transition identification, especially for stages B and C.

A case scenario study on adherence to COPD GOLD recommendations by general practitioners in a rural area of southern Italy: The "progetto PADRE"

The aim of the present study was to evaluate in a sample of 200 patients diagnosed with COPD and selected from the physician database of 15 general practices from Valle Telesina (Benevento, Italy) if the diagnostic-therapeutic algorithm adopted by GPs operating in a non-urban district in Southern Italy adhered to GOLD 2018 recommendations for COPD. Each patient underwent a specialist visit by an experienced chest physician that collected anamnesis, assessed mMRC and CAT scores, and performed a spirometry. In case of diagnostic doubt, a second visit was performed at the Pulmonary Rehabilitation Unit of the Istituti Clinici Scientifici Maugeri IRCCS in Telese Terme where other diagnostic tests were performed. Our results showed that GPs participating in the study often diagnosed and empirically treated COPD without a confirmative spirometry or even despite a spirometry that was not diagnostic of obstructive lung disease. Furthermore, real-life implementation of GOLD strategy, as regards patients' ABCD categorization, was poor and many patients belonging to groups A and B (39% and 48%, respectively) were over-treated and 19% of those belonging to group D were under-treated. The discrepancy between guidelines and daily clinical practice present also in this study supports the opinion of many that those who develop guidelines for the management of COPD must seriously try to understand if and why the guidelines might not reflect real life and therefore how it could be improved.

Evaluation of Changes in Control Status in COPD: An Opportunity for Early Intervention

BACKGROUND

Control has been proposed as a dynamic tool that can capture changes in the clinical status of patients with COPD.

METHODS

This prospective, multicenter, observational study aimed to compare changes in control over a 3-month period with changes in risk level, Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage, and clinical phenotype (nonexacerbator, asthma-COPD overlap, or exacerbator with emphysema or with chronic bronchitis). Control was defined as the presence of low clinical impact, assessed according to the degree of dyspnea, use of rescue medication, physical activity and sputum color, and clinical stability assessed by clinical changes and exacerbations in the last 3 months. Impact and stability were alternatively assessed with COPD Assessment Test (CAT) scores.

RESULTS

We included 354 patients, with a mean FEV₁ of 49.8% ± 16.9%. At 3 months, the proportion of controlled patients was 50.3% according to clinical evaluation and 47.8% according to CAT score. Eighty-seven patients (29.2%) changed their control status as assessed by clinical variables, and 85 patients (28.5%) changed their status according to CAT score. In contrast, the risk level only changed in 26 patients (8.7%) (P < .001), 27 patients (9.1%) experienced changes in their clinical phenotype (P < .001), and 59 patients (19.8%) experienced changes in their GOLD stage (P = .008). Patients who showed an improvement in control status had better CAT scores at the end of follow-up (P < .001).

CONCLUSIONS

In only 3 months, almost one-third of patients experienced changes in their control status. Changes in control status were significantly more frequent than changes in phenotype, risk level, and GOLD stage, and resulted in significant changes in health status.

Prognosis of COPD depends on severity of exacerbation history: A population-based analysis

BACKGROUND

Differences in previous exacerbation history may influence prognosis of chronic obstructive pulmonary disease (COPD). We hypothesized that prognosis differs between individuals with a history of only medically treated exacerbations (moderate exacerbations) and those with a history of hospitalised exacerbations (severe exacerbations).

METHODS

We included 98 614 adults from the Copenhagen General Population Study and assessed risk of moderate and severe exacerbations, pneumonia hospitalisation, and respiratory and all-cause mortality from 2003 until 2013 according to exacerbation history.

RESULTS

Among 6545 individuals with COPD, 6290 had no exacerbations in the preceding year, 109 had one moderate exacerbation, 108 had two or more moderate exacerbations, and 38 had one or more severe exacerbations. During 9.4 years of follow-up, we observed 926 moderate and 244 severe exacerbations, 477 pneumonias, and 707 deaths, including 69 from respiratory disease. Compared to individuals without previous exacerbations, lung function and symptom adjusted hazard ratios (HRs) for future moderate exacerbation were 4.68 (95% confidence interval:3.31-6.62) for individuals with one previous moderate exacerbation, 21 (13-33) for individuals with two or more previous moderate exacerbations, and 5.30 (3.44-8.15) for individuals with one or more previous severe exacerbations. Corresponding HRs were 1.62(0.78-3.34), 1.29(0.57-2.89), and 5.43 (2.56-12) for severe exacerbation, 1.86(1.06-3.27), 1.74(1.01-2.99), and 4.85 (2.94-8.02) for pneumonia, 0.53(0.10-2.99), 1.65(0.53-5.17), and 2.98 (1.14-7.83) for respiratory mortality, and 1.34(0.79-2.29), 1.57(1.00-2.47), and 1.49 (0.85-2.62) for all-cause mortality, respectively.

CONCLUSION

Individuals with COPD and a history of hospitalised exacerbations carried the poorest prognosis compared to those with a history of only medically treated exacerbations, suggesting difference in risk profile.

Disease awareness in patients with COPD: measurement and extent

Background

Patient awareness of COPD refers to knowledge and acceptance of the disease and its treatment. Although it is relevant to management and outcomes, the disease awareness of patients is poorly investigated, and no validated questionnaires are currently available. We aimed to develop the novel Disease Awareness in COPD Questionnaire (DACQ), which was validated in relation to demographic and clinical features, in patients participating in the SATisfaction and Adherence to COPD Treatment (SAT) study.

Methods

DACQ was developed according to a list of items regarding the patient’s knowledge, acceptance, and perception of COPD as well as of treatment needs. The questionnaire was validated by assessing internal structure and consistency, correlations with other patient-reported outcomes, and stability over time. Furthermore, the extent of disease awareness of patients enrolled in the SAT study was assessed by using DACQ, and correlations with demographic and clinical features were evaluated.

Results

DACQ was composed of four domains. Overall reliability and stability over time were adequate; correlations between DACQ and other tools measuring different constructs (ie, treatment satisfaction, illness perception, impact of COPD symptoms on daily life, and dyspnea severity) were, as expected, more limited. In the enrolled patient sample, a suboptimal level of disease awareness (<70%) was detected, especially in terms of disease acceptance and perception. Disease knowledge was positively associated with COPD severity, while the impact of symptoms on daily life was negatively associated with disease acceptance, awareness of treatment needs, and overall awareness.

Conclusion

DACQ proved to be a reliable tool to assess awareness in COPD patients. Awareness of COPD patients need to be improved.

Clinical trial registration

ClinicalTrials.gov ID# NCT02689492.