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      Changes in Global Initiative for Chronic Obstructive Lung Disease ABCD Groups and the Impact of Regrouping on Treatment: A Comparison of 2017 and 2014

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          Abstract

          To the Editor: In 2017, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a total revised document (GOLD 2017),[1] in which one important change is the “ABCD” classification for the management of patients with chronic obstructive pulmonary disease (COPD). The assessment tool of the GOLD 2011 combined the symptomatic assessment with the patient's spirometric classification and/or risk of exacerbations, and the revised GOLD 2014[2] added the history of hospitalization due to an exacerbation in the preceding year as a method of assessing exacerbation risk. However, increasing evidence suggested the limitations of the forced expiratory volume in 1 s (FEV1) in influencing prognostic and therapeutic decisions. The new GOLD 2017 classification separates spirometric grades from the “ABCD” groups.[1] To date, the impact of this revision on grouping and subsequent drug selection has been insufficiently studied. Recently, a multicenter, observational, and cross-sectional study was conducted to compare the effects of the GOLD 2014 and 2017 on the grouping and treatment of COPD patients in Hunan, China. All data were obtained from the records of clinically stable outpatients aged >40 years in 2016 and 2017 with COPD, according to the diagnostic criteria of the GOLD 2017. Patients with other active or chronic respiratory diseases that needed to be diagnosed, intervened, or treated were excluded. In 561 COPD patients, the distributions from Groups A to D were 17 (3.0%), 147 (26.2%), 6 (1.1%), and 391 (69.7%) to 19 (3.4%), 280 (49.9%), 4 (0.7%), and 258 (46.0%), according to the GOLD 2014 and 2017, respectively. The new classification led to 2 patients (33.3% of Group C) moving from Group C to Group A, and 133 patients (34.0% of Group D) moving from Group D to Group B. Thus, more than one-third of patients formerly classified into Group D with predicted FEV1 <50% had no history of frequent acute exacerbation. Now, this part of patients was reclassified into Group B. Recently, Tudoric et al.[3] also showed 35.6% patients in Group D moved to Group B, according to the revised classification. In China, Sun et al.[4] conducted a national cross-sectional observational survey performed in 11 medical centers of seven provinces. The results indicated that 46.7% patients in high-risk groups were regrouped to low-risk groups. Such changes were consistent with the results of this study. The GOLD 2017 recommended initial therapy with long-acting beta-agonist (LABA) and/or long-acting muscarinic antagonist (LAMA) for patients in Group B and a LABA/LAMA combination for patients in Group D. Although the patients moved from Group D to Group B had poor pulmonary function, we found that their prescriptions were usually triple-inhaled therapies rather than LABA + LAMA. Specifically, a total of 103 (77.4%) of 133 patients who shifted from Group D to Group B were treated with inhaled corticosteroids (ICS). Of these, 94 (91.3%) used ICS + LABA + LAMA and 9 (8.7%) used ICS + LABA. It suggested that, as for these newly classified patients, dual bronchodilation should be the first-line therapy and ICS should be applied less. In conclusion, the new classification significantly decreases the proportion of patients in high-risk groups, which also affects the therapeutic decisions to a lesser degree. The regrouping may lead to a decrease in the use of ICS. As a result, ICS-related complications, such as pneumonia and pulmonary tuberculosis, can be reduced. According to the new GOLD 2017, ABCD groups will be derived exclusively from patient symptoms and their history of exacerbation, which seems to be on the way to individualized medicine and may improve the prognosis. Of note, in China, patients often refuse to seek medical help until severe symptoms appear. This led to the limited number of patients in Groups A and C in this study. Another reason was that patients with a COPD Assessment Test (CAT) score ≥10 and Modified British Medical Research Council grade ≥2 accounted for 95.9% and 64.5%, respectively. Most patients were divided into Groups B and D because of higher CAT scores. Several studies have found that lung function and previous exacerbation history were different in predicting prospective exacerbation rates, and the exacerbation history was the best predictor.[5] A large sample size study is needed to further research whether the revised ABCD categories provide any prognostic information on disease progression over time. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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          GOLD 2011 disease severity classification in COPDGene: a prospective cohort study.

          The 2011 GOLD (Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease [COPD]) consensus report uses symptoms, exacerbation history, and forced expiratory volume (FEV1)% to categorise patients according to disease severity and guide treatment. We aimed to assess both the influence of symptom instrument choice on patient category assignment and prospective exacerbation risk by category. Patients were recruited from 21 centres in the USA, as part of the COPDGene study. Eligible patients were aged 45-80 years, had smoked for 10 pack-years or more, and had an FEV1/forced vital capacity (FVC) <0·7. Categories were defined with the modified Medical Research Council (mMRC) dyspnoea scale (score 0-1 vs ≥2) and the St George's Respiratory Questionnaire (SGRQ; ≥25 vs <25 as a surrogate for the COPD Assessment Test [CAT] ≥10 vs <10) in addition to COPD exacerbations in the previous year (<2 vs ≥ 2), and lung function (FEV1% predicted ≥50 vs <50). Statistical comparisons were done with k-sample permutation tests. This study cohort is registered with ClinicalTrials.gov, number NCT00608764. 4484 patients with COPD were included in this analysis. Category assignment using the mMRC scale versus SGRQ were similar but not identical. On the basis of the mMRC scale, 1507 (33·6%) patients were assigned to category A, 919 (20·5%) to category B, 355 (7·9%) to category C, and 1703 (38·0%) to category D; on the basis of the SGRQ, 1317 (29·4%) patients were assigned to category A, 1109 (24·7%) to category B, 221 (4·9%) to category C, and 1837 (41·0%) to category D (κ coefficient for agreement, 0·77). Significant heterogeneity in prospective exacerbation rates (exacerbations/person-years) were seen, especially in the D subcategories, depending on the risk factor that determined category assignment (lung function only [0·89, 95% CI 0·78-1·00]), previous exacerbation history only [1·34, 1·0-1·6], or both [1·86, 1·6-2·1; p<0·0001]). The GOLD classification emphasises the importance of symptoms and exacerbation risk when assessing COPD severity. The choice of symptom measure influences category assignment. The relative number of patients with low symptoms and high risk for exacerbations (category C) is low. Differences in exacerbation rates for patients in the highest risk category D were seen depending on whether risk was based on lung function, exacerbation history, or both. National Heart, Lung, and Blood Institute, and the COPD Foundation through contributions from AstraZeneca, Boehringer Ingelheim, Novartis, and Sepracor. Copyright © 2013 Elsevier Ltd. All rights reserved.
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            GOLD 2017 on the way to a phenotypic approach? Analysis from the Phenotypes of COPD in Central and Eastern Europe (POPE) Cohort.

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              Changes in definition lead to changes in the clinical characteristics across COPD categories according to GOLD 2017: a national cross-sectional survey in China

              Purpose To investigate how the changes of definition in assessment of Global Initiative for Chronic Obstructive Lung Disease (GOLD) stratification 2017 lead to changes of chronic obstructive pulmonary disease (COPD) patient clinical characteristics across categories in China. Patients and methods COPD patients from 11 medical centers in China were stratified into old and new groups A–D twice according to the GOLD 2011 and 2017 comprehensive assessment. Demography and clinical characteristics were compared between old and new groups A–D. Results In 1,532 COPD patients, the distribution from group A to D was 330 (21.5%), 132 (8.6%), 411 (26.8%), 659 (43.0%) and 557 (36.4%), 405 (26.4%), 184 (12.0%), 386 (25.2%), respectively according to GOLD 2011 and 2017. 46.7% (500/1,070) patients in high-risk groups were regrouped to low-risk groups. Compared to the old groups A and B, the new groups A and B had a higher proportion of males, lower body mass index, higher modified Medical Research Council (mMRC) grade, poor pulmonary function, more patients with chronic bronchitis, and fewer patients with coronary heart disease and hypertension disease. Compared to the old groups C and D, the new groups C and D had older patients, fewer men, better pulmonary functions, frequent acute exacerbations in the previous year, and more patients with chronic bronchitis, coronary heart disease, or diabetes mellitus. The new group D had more patients with stroke than the old group D. Conclusion In China, GOLD 2017 shifted the overall COPD comprehensive assessments distribution to more low-risk groups. The new high-risk groups had more characteristics associated with high risk of acute exacerbation and mortality. Some of the changes in demography and clinical characteristics of the new low-risk groups were associated with high risk of acute exacerbation and/or mortality.
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                Author and article information

                Journal
                Chin Med J (Engl)
                Chin. Med. J
                CMJ
                Chinese Medical Journal
                Medknow Publications & Media Pvt Ltd (India )
                0366-6999
                05 May 2018
                : 131
                : 9
                : 1113-1114
                Affiliations
                [1]Department of Respiratory Medicine, The Second Xiangya Hospital of Central South University, Changsha, Hunan 410011, China
                Author notes
                Address for correspondence: Dr. Yan Chen, Department of Respiratory Medicine, The Second Xiangya Hospital of Central South University, No. 139 Renmin Road, Changsha, Hunan 410011, China E-Mail: chenyan99727@ 123456csu.edu.cn
                Article
                CMJ-131-1113
                10.4103/0366-6999.230737
                5937323
                29692385
                78ab0d6a-1db9-4aef-9080-68129f2c1401
                Copyright: © 2018 Chinese Medical Journal

                This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

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