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Vol. 59. Issue 4.
Pages 193-194 (April 2023)
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Vol. 59. Issue 4.
Pages 193-194 (April 2023)
Editorial
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GOLD 2023: What's New, Doc?
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Alvar Agustia,b,c,d,
Corresponding author
aagusti@clinic.cat

Corresponding author.
, Bartolome R. Cellie
a Cátedra de Salud Respiratoria, Universidad de Barcelona, Spain
b Servei Pneumologia, Institut Respiratori, Clinic Barcelona, Spain
c IDIBAPS, Barcelona, Spain
d CIBERES, Spain
e Brigham and Women's Hospital. Harvard Medical School, Boston, USA
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Arch Bronconeumol. 2023;59:232-4810.1016/j.arbres.2023.02.009
Alvar Agustí, Bartolome R. Celli, Gerard J. Criner, David Halpin, Antonio Anzueto, Peter Barnes, Jean Bourbeau, MeiLan K. Han, Fernando J. Martinez, Maria Montes de Oca, Kevin Mortimer, Alberto Papi, Ian Pavord, Nicolas Roche, Sundeep Salvi, Don D. Sin, Dave Singh, Robert Stockley, M. Victorina López Varela, Jadwiga A. Wedzicha, Claus F. Vogelmeier
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This issue of Archivos de Bronconeumología features an executive summary of the new 2023 Global Initiative for Chronic Obstructive Lung Disease (GOLD) recommendations for the diagnosis and clinical management of patients with chronic obstructive pulmonary disease (COPD) 1. This executive summary is also being published simultaneously in another four international journals (Am. J. Respir. Crit. Care Med., Eur. Respir. J., Respirology and J. Pan African Thor. Soc) in order to distribute these recommendations globally at the same time. Archivos de Bronconeumología is the official journal of the Latin American Thoracic Association, and as such, the executive summary is being published in Spanish, too. In this editorial, we highlight what we think are the most important changes. We suggest that interested readers read the executive summary in detail and, if more specific information is needed, access the full document which available free of charge on the GOLD website (www.goldcopd.org), where they will find also a slide set and a pocket guide.

The knowledge and management of COPD has evolved significantly in recent years. COPD has traditionally been thought of as a disease of men over the age of 60, self-inflicted by smoking and characterized by an accelerated loss of lung function with age 2. However, while smoking remains the principal environmental risk factor 3, we now know that other genetic, epigenetic and/or environmental factors can lead to COPD 4–6, that the incidence of the disease in men and women is similar 7, that it is not always characterized by an accelerated loss of lung function [pre- and post-natal events that modulate lung development play a very important role in this respect 6,8], and that COPD can appear in young patients 9. This new knowledge has led the GOLD 2023 science committee to adopt a new definition of the disease that clearly differentiates the characteristics of the disease from its causes and risk factors, and to propose a new taxonomy based on its possible causes (etiotypes) 10,11. This proposal recognizes that smoking is still the main environmental risk factor, but since about 30% of COPD patients worldwide are never-smokers 3, so etiotypes of the disease in non-smokers need to be identified. The importance of abnormal lung development in the pathogenesis of COPD has been recognized 6,8, and as a result, the terms early, mild, young, pre-COPD and PRISm (“preserved ratio impaired spirometry”) are also discussed and defined.

Other practical aspects discussed in GOLD 2023 include an extensive review of the clinical relevance of the “traditional” chronic bronchitis and the use of computed tomography (CT) in the clinical management of COPD patients. The potential of CT scans to identify previously undiagnosed (and therefore untreated) comorbidities 12 and the importance of this procedure in the early diagnosis of lung cancer in these patients have been demonstrated.

GOLD 2023 proposes a major modification of the patient classification system: the former four groups (A,B,C,D) are now condensed into three (A,B,E), the new group E (exacerbations) including the old groups C and D. The main reasons for this proposal is that exacerbations have a significant clinical impact 13,14, independent of the level of symptoms (the variable that differentiated groups C and D), and that the perception of dyspnea varies greatly among patients with frequent and infrequent exacerbations 15. In fact, patients generally change their lifestyle to minimize symptoms. This new classification proposal (that still has to be validated prospectively) is accompanied by significant changes in the recommendations for initial pharmacological treatment. GOLD 2023 proposes dual bronchodilation (LABA-LAMA) in most patients with COPD (except perhaps in patients in group A). In patients in group E with >300 eosinophils/μL, the initiation of triple therapy with inhaled corticosteroids (LABA-LAMA-ICS) may also be considered, as this type of treatment has been shown to reduce all-cause mortality in these patients 14,15. Furthermore, according to GOLD 2023, LABA-ICS is not considered a good alternative in patients with COPD, since, if treatment with ICS is required, it should be added to the dual bronchodilator therapy (LABA-LAMA) already in place 7. Finally, GOLD 2023 emphasizes strongly the importance of appropriate use of inhalers (no matter which one is prescribed) and the need for continuous evaluation of patient's response to treatment with adjustment according to this response, considering two main treatable traits16 (dyspnea and exacerbations) as it was proposed already in previous GOLD recommendations.

GOLD 2023 emphasizes the importance of vaccination against the various preventable diseases that are of particular significance in COPD patients (including influenza, pneumococcus, herpes zoster, diphtheria-pertussis and SARS-CoV2). Finally, it proposes a new definition of exacerbations and a new set of severity criteria to be assessed at the point of contact with the patient 17, which should also be validated in prospective studies 14.

All these new proposals reflect current knowledge in COPD, but GOLD documents will continue to evolve in parallel with the generation of new scientific evidence. We hope that you find these recommendations sound and of interest in your daily clinical practice.

References
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A. Agustí, B.R. Celli, G.J. Criner, D. Halpin, A. Anzueto, P. Barnes, et al.
Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary.
Arch Bronconeumol., 59 (2023), pp. 232-248
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