Updated COPD Management Recommendations by GOLD

COPD Management Recommendations by GOLD Committee

On  World COPD Day (November 16, 2016) updated recommendations for management of those with COPD were released. The group of experts from throughout the world who made the recommendations is called the GOLD committee. GOLD stands for Global Initiative for Chronic Obstructive Lung Disease.

Bartolome Celli, M.D., of Brigham and Women's Hospital

Bartolome Celli, M.D., of Brigham and Women’s Hospital

Pulmonary physicians from the United States on the Board of Directors of GOLD include: Bartolome Celli, M.D., of Brigham and Women’s Hospital in Boston and Gerald Criner, M.D., of Louis Katz School of Medicine in Philadelphia.

Dr. Criner is on the Board of Directors which makes COPD management recommendations

Gerald Criner, M.D., Chair and Professor, Thoracic Medicine and Surgery



The COPD management recommendations can be found on the website: http://goldcopd.org. The major goals of treatment are to reduce symptoms (shortness of breath) and to reduce the risk of sudden worsening (called an exacerbation).

The following statements summarize the recommendations for personalized treatment of those with stable COPD.

  1. Long-acting bronchodilators (last 12 – 24 hours) are preferred over short-acting drugs (last 4 – 6 hours) for those with occasional shortness of breath.
  2. Either one or two long-acting bronchodilators may be used as initial treatment.  Increase to two bronchodilators is recommended if improvement is not achieved with one drug. The three approved dual bronchodilators available for prescription in the US are shown below.
    Anoro Ellipta enables patients to breathe easier with two bronchodilators

    Anoro Ellipta dry powder inhaler

    Stiolto Respimat delivers a fine mist.

    Stiolto Respimat delivers a fine mist.


    Bevespi contains two different bronchodilators in a single device

    Bevespi is a pressurized metered-dose inhaler

  3. For those who have a history of sudden worsening of COPD (exacerbation), use of an inhaled corticosteroid may be considered in addition to a long-acting beta-agonist bronchodilator (Advair, Symbicort, and Breo).
  4. For severe hereditary alpha-1 antitrypsin deficiency, replacement therapy (also called augmentation therapy) should be considered.
  5. Medicines to suppress coughing (called antitussives) are not recommended.
  6. If breathing difficulty is severe and disabling, low dose narcotics (opioids like morphine) may be considered.

These COPD management recommendations are based on the results of published clinical trials.   

November is National COPD Awareness Month: Wear Orange

World COPD Awareness Day is November 16 

An estimated 24 million Americans suffer from COPD, while almost one-half have not yet been diagnosed. It is likely that these individuals who don’t know that they have COPD blame their shortness of breath on “getting older” or being “out of shape.”

With early diagnosis and treatment, people with COPD can improve their quality of life and begin to breathe a little easier.

Woman promoting COPD awareness

Woman with COPD using portable oxygen system

As part of National COPD Awareness Month, many organizations and individuals are trying to raise COPD awareness by hosting events, leading discussions, and conducting other outreach activities to help people take the first step toward improving the lives of those with COPD.

The US COPD Coalition urges the nation to “GO ORANGE” for COPD in November. The color ORANGE calls attention to and provides visual solidarity among efforts across the nation. ORANGE is also the color that the U.S. Environmental Protection Agency’s Air Quality Index uses to represent days with unhealthy air quality for sensitive groups, including people with lung disease.

Breathe New Hampshire
is sponsoring a COPD Wellness Workshop from 10 am – 12 noon on November 19 @ 145 Hollis St., Unit C, Manchester, NH  03101
603-669-2411 or 800-835-8647  email info@breathenh.org

I and other panelists will be presenting information about COPD and will answer questions. I hope to see you there.

Key facts about COPD:

  1. It is the 3rd leading cause of death in the US.
  2. 5.2% of adult men and 6.7% of adult women have COPD.
  3. Alpha-1 antitrypsin deficiency is a genetic risk factor for emphysema/COPD. If you have not been tested, ask your health care provider to order the blood test.

Additional information is available on the COPD Foundation website: http://www.copdfoundation.org

My Sister died from Complications of Alpha-1

Good Afternoon Dr. Mahler:

I hope you can help me with some information about Alpha-1. My sister recently died from complications of Alpha-1, this was diagnosed through an autopsy. We have no idea how long she was suffering with the disease, but was admitted to the hospital and passed 5 days later from cirrhosis, spontaneous peritonitis, and sepsis. Such a shock. I had my blood test and found that I am a carrier and unlikely? to have problems. I do have asthma and nodules in my lung so I am very concerned.

Would you suggest I have further tests to assure my lung issues

Would you suggest I have further tests to assure my lung issues are not related to Alpha 1? Thank you in advance for your assistance.

Judy from Kalamazoo, MI

Dear Judy,

I am sorry to hear about your sister.

It is important to remember that alpha-1 antitrypsin deficiency (abbreviated Alpha-1) is a liver disease that can affect the lungs, especially if someone smokes.  The Alpha-1 protein is made in the liver and is called a protease inhibitor – this means that it protects the lung from damage. The condition is most common among Europeans and North Americans of European descent.

Cirrhosis affects about 30-40% of those with Alpha-1 over the age of 50 years.  Unless your mother had another reason to have cirrhosis (like hepatitis or excess alcohol intake), her cirrhosis was likely due to Alpha-1 disease. Your health care provider should be able to tell you this from the autopsy results.

You stated that you are a carrier.  You should ask you health care provider for the exact results.  This includes the alleles (two letters) and the level of Alpha-1 in the blood.  Being a carrier means that you probably have a Z or S allele (inherited from one parent); the other allele is probably M, which is normal.  You should share this information with any siblings and children, who can then tell their health care provider.

You are correct that it is very unlikely that you will have any liver or lung problem as a carrier for Alpha-1.  Certainly, it is quite important that you do not smoke cigarettes or inhale irritants in the air.

The figure shows possible conditions associated with Alpha-1 deficiency.

Conditions associated with Alpha-1


In response to your question about additional tests:

Has your health care provider told you what is the cause of the lung nodules? There are many causes for lung nodules, and the key issue is to determine that they are benign (not cancer).  Usually, follow-up CT scans of the chest are done to make sure that the nodules are stable in size over a 2 year period.  If so, then it is assumed that the nodules are benign.

Asthma is diagnosed by a medical history AND breathing tests. If you have not had pulmonary function tests (breathing tests), you should request these.  The information can help in making the correct diagnosis and in determining how your lungs are working.  As the above figure indicates, sometimes Alpha-1 can be misdiagnosed as asthma.

Finally, the Alpha-1 Foundation is a great resource for more information.

Best wishes,

Donald A. Mahler, M.D.




Alpha-1 News

Food and Drug Administration holds meeting on Alpha-1 Antitrypsin Deficiency

On September 29, 2015, Alphas and Alpha-1 caregivers packed a public meeting held by the US Food and Drug Administration to discuss Patient-Focused Drug Development for Alpha-1 Antitrypsin Deficiency. About 250 people filled the room, while about 600 attended online.

Alpha-1 Foundation Board member Liz Johnson explained the impact of Alpha-1 on daily life based on results of a survey of just under 1,700 response: 1. Nearly 100% of those with Alpha-1 affecting their lungs reported shortness of breath.  2. 37% of these individuals reported that shortness of breath had a significant or extremely significant effect on their daily lives,  including dressing, washing, bending down, or tying shoes. 3. 72% of the total noted breathlessness with exercise. 4. Among those affected with liver involvement, 74% reported abdominal pain as a symptom, and 73% had abdominal swelling.

Fred Walsh, AlphaNet coordinator

Fred Walsh, AlphaNet coordinator

AlphaNet coordinator Fred Walsh commented that: “Pulmonary rehab is essential and should be widely available and inexpensive. A rescue inhaler can help everybody. I can’t believe there is no generic version of albuterol.”

Most speakers said that they were satisfied with augmentation therapy, but nearly all expressed the need for new therapies, especially for Alpha-1 liver disease.

Pujita Vaidya, MPH, gave an overview of the Patient-Focused Drug Development Initiative and said that the FDA will summarize patient testimony with a summary of “What We Learned,” from the Alpha-1 hearing.