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GOLD 2024 Report for COPD
A New GOLD Standard: Updates in Managing COPD

Released: January 16, 2024

J. Andrew Woods
J. Andrew Woods, PharmD, BCPS
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Key Takeaways
  • The 2024 GOLD Report discusses expansions of understanding surrounding the pathophysiology and etiology of COPD, emphasizing the role non-cigarette pollutants play in this condition.
  • The updated report highlights the importance of appropriately assessing and addressing adherence concerns, including facilitating medication access, and selecting appropriate therapies with each patient.
  • To improve adherence, the teach-back method is an effective tool that enables patients to demonstrate a more sustained mastery of medication administration, thereby facilitating adherence.

There are many challenges in optimally managing COPD, including underdiagnosis, inequitable access to therapy, and struggles with medication adherence, which can be complicated for many patients. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has recently provided the 2024 guidance report, which is an invaluable resource for healthcare professionals (HCPs) across care settings caring for patients with COPD.

Updates in the GOLD Report: What Pharmacists in All Settings Need to Know

Diagnosis and Classification

The 2024 GOLD Report updates have provided an expanded understanding of the pathophysiology and etiology of COPD. These updates make it clear that pharmacists in all care settings must recognize COPD as not just a “smoking disease,” or a condition exclusive to those who smoke or have historically smoked cigarettes. There is growing confidence that multiple etiologies contribute to the development of COPD. In addition, recent GOLD updates have provided a simplified staging scheme. The updated report maintained the 2023 classification updates, whereby COPD severity is simplified to AB or E, rather than ABC or D. The new stage E combines previous stages C and D.

In light of our improved understanding of COPD pathophysiology and etiology, it is ever more crucial for HCPs to recognize the role pharmacists can play in the timely diagnosis and classification of this condition. Pharmacists in the clinic setting should be cognizant when caring for patients with respiratory complaints or conditions to consider if the patient could have uncontrolled or undiagnosed COPD. I believe that familiarity with the most recent research can improve a pharmacist’s ability to recognize the various potential COPD etiologies outlined in the literature/GOLD report, such as cigarette smoking or various types of pollution exposure. Biomass fuel pollutants, occupational exposures, and air pollution are contributors we would frequently overlook or undervalue as potential etiologies.

Pharmacists in the ambulatory care or community setting frequently care for patients with conditions that commonly coexist with COPD (eg, diabetes, obesity). These visits may provide critical opportunities for them to identify signs of undiagnosed or undermanaged COPD. If COPD is possible or suspected, the pharmacist can then request or order a referral for evaluation, or, if they have the training and resources needed, perform the spirometry themselves.

Therapy and Device Considerations 

Currently, choosing the best, evidence-based pharmacotherapy for COPD is relatively simple. Most patients with COPD who require maintenance therapy should be prescribed a long-acting antimuscarinic agent (LAMA) and long-acting beta-agonist (LABA) combination. Not much has changed regarding this recommendation in the most recent update. A small subset of patients, such as those with a history of hospitalization for COPD, 2 or more COPD exacerbations yearly, elevated blood eosinophils equal to or greater than 300 cells per microliter, and a history of, or concurrent asthma, may also benefit from an addition of an inhaled corticosteroid thereafter.

Getting the patient on the best medication device may prove more challenging. There are currently 22 or more different inhaler types or devices available that deliver 33 different inhaled therapies, so there is a bevy of options to choose from. These are comprised of metered-dose inhalers (MDI), slow-mist or soft-mist inhalers (SMI), dry-powder inhalers (DPI), and nebulizers. There are several fixed-dose combination products that pair 2 or more agents in 1 inhaler; these are great options for reducing inhaler and cost burden for patients once they are stable on their regimen. The Allergy & Asthma Network has an updated poster available for HCPs to download with currently approved respiratory treatments depicted and categorized.

In the clinic setting, it is optimal to have placebo or dummy devices to use for training and counseling patients about their medications. Oftentimes, these are provided by the manufacturer of the products. With these props, you can see how a patient handles a device and assess their hand strength, dexterity, and inhalation maneuver. I frequently use the In-Check DIAL device, which allows for a more thorough assessment of inhaler technique—specifically a patient’s inspiratory maneuver relative to their prescribed device—and provides guidance on device selection. HCPs can obtain this device along with disposable mouth pieces from the manufacturer. In addition, pharmacists should assess the patient’s technique at every encounter, in particular, their inhalation maneuver. This assessment can play an important role in ensuring each patient is paired with the best device for them. Ultimately, we can choose the right pharmacotherapy classes of medications, but treatment will only be successful if we choose the correct device to ensure that the inhaled medication is delivered into the lower airways where it belongs.

Facilitating Access and Adherence

The 2024 update puts great emphasis on the importance of medication access and adherence. In particular, this report is more specific and deliberate than previous editions in mentioning challenges with and best practices in navigating access and adherence concerns. Pharmacists should recognize that many patients with COPD experience healthcare inequities, which compound and complicate their care. These may include residing in a high pollution area, working in environments with high pollution exposure, and lacking sufficient healthcare insurance to access medication consistently.

HCPs should also endeavor to understand each patient’s specific barriers to adherence. Nonadherence may not be due to a patient’s lack of effort in using their medication as directed. Instead, the patient may struggle to use the prescribed device properly and in a consistent way. Rather than assuming the patient is managing their medication on their own, we as HCPs should facilitate ongoing access and adherence. This can be accomplished in many ways, such as helping with the best device selection, navigating insurance coverage hurdles, and using the teach-back method to assess adherence and technique at every encounter, across practice settings.

An approach I use with all patients to optimize care, access, and adherence is to consolidate and simplify a patient’s regimen to 1 inhaler type, and where possible, a fixed-dose inhaler combination that has the agents they need in 1 device. Even if those inhalers are the same classification, namely MDI, DPI, or SMI, the likelihood that a mistake or nonadherence occurs will be much higher if they are on multiple inhalers or device types.

Providing Effective Patient Counseling: The Teach-Back Method
The teach-back method is a particularly effective tool when teaching patients about a new device and reinforcing the appropriate technique at subsequent visits. In this method, a patient will explain in their own words or demonstrate what an HCP has taught them. If they understand the concept, they will be able to “teach-back” what they have learned. Any misunderstandings can then be clarified by the HCP, repeating the teach-back process until the patient demonstrates competence in the taught information or skills. The literature consistently demonstrates that pharmacists are particularly skilled at using this method. Although there is a plethora of educational materials about inhaler use, such as brochures and videos, the teach-back method of counseling results in a more durable educational impact.

As with any method, retention of the information will wane over time, hence the importance of emphasizing consistent use at every encounter. With inhalers, use of the teach-back strategy at follow-up would include having the patient demonstrate their technique on a placebo device or their own device, without fully activating the dose.  This would offer the opportunity to correct technique at each step, allowing the patient to improve while being coached and observed. This method can also offer the HCP an opportunity to adjust the patient’s inhaler type if they observe a mismatch between the current prescription and the patient’s capacity for using it correctly.

Your Thoughts?
How can you adjust your practice setting to improve medication access and adherence to COPD therapies? Find more information on this program by reading the CE-certified text module titled Strategies for Pharmacists to Overcome Current Challenges and Integrate Novel Maintenance Therapies for the Management of COPD and accessing the accompanying downloadable slideset. You can also join the discussion by posting a comment below.

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