Summarizing the 2021 Updated GOLD Guideline for COPD

Mackenzie Laisure, PharmD Candidate 2022; Nicole Covill, PharmD Candidate 2022; Marissa L. Ostroff, PharmD, BCPS, BCGP; Jared L. Ostroff, PharmD, MBA, BCACP, BCGP


US Pharmacist. 2021;46(7):30-36. 

In This Article

Nonpharmacologic and Preventative Therapy

Nonpharmacologic therapy for COPD includes smoking cessation, physical activity, and vaccination. Smoking cessation is important to prevent disease progression. Patients with COPD who are current smokers should be assessed for willingness to quit smoking and be provided with education on how to quit.

According to the 2021 GOLD guidelines, counseling by healthcare professionals, even for brief periods of time, significantly increases quit rates over self-initiated strategies. The recommended treatment for smoking cessation is nicotine-replacement therapy (NRT) with agents such as nicotine gum, inhalers, nasal spray, transdermal patches, sublingual tablets, or lozenges. Other pharmacologic agents such as varenicline, bupropion, and nortriptyline have been shown to increase long-term quit rates, but these should only be used as part of a supportive intervention program rather than monotherapy for smoking cessation.

The use of e-cigarettes for smoking cessation has been gaining popularity over recent years. These products provide a vaporized nicotine to be inhaled. While e-cigarettes have been available for over 15 years, the safety and efficacy data of e-cigarettes as a smoking cessation tool are still uncertain. In addition to nicotine, vape products are made with chemicals such as vegetable glycine, flavoring agents, volatile carbonyls, diacetyl, reactive oxygen species, furones, metals, and others. Severe acute lung injury, eosinophilic pneumonia, alveolar hemorrhage, respiratory bronchiolitis, other lung abnormalities, and even death have been linked to e-cigarette use.

One randomized, controlled trial by Bullen et al investigated the efficacy of e-cigarettes compared with nicotine patches in helping people to quit smoking.[3] A total of 657 participants were randomized in a 4:4:1 ratio to 16-mg nicotine e-cigarettes, 21-mg once-daily nicotine patches, or placebo e-cigarettes. The primary outcome measure was biochemically verified continuous abstinence from smoking after 6 months. At this 6-month mark, 7.3% participants in the e-cigarette group had verified abstinence, 5.8% in the nicotine patch group, and 4.1% in the placebo group. However, there was insufficient statistical power to conclude the superiority of nicotine e-cigarettes over patches.

Another randomized, controlled trial by Hajek et al compared the efficacy of e-cigarettes to NRT of the patient's choice.[4] Randomization included 446 patients in the NRT group and 438 in the e-cigarette group. The primary outcome measure was sustained abstinence rates at 52 weeks. The NRT group had a 1-year quit rate of 9.9%, while the e-cigarette group had a rate of 18%. These results were deemed statistically significant with P <.001. This trial also found that participants in the e-cigarette group showed significantly better adherence and experienced fewer urges to smoke in the initial 4 weeks of quitting. Due to possible risks and a lack of further data, the 2021 GOLD guidelines do not make a recommendation for the use of e-cigarettes for smoking cessation.

Patients with COPD are also at higher risk for serious complications from certain vaccine-preventable illnesses.[5] Pneumococcal vaccination, PPSV23, may be recommended for patients aged 19 to 64 years with COPD if they have significant comorbidities, including chronic lung or heart disease, to reduce the incidence of community-acquired pneumonia. One of the key changes to the 2021 update to the GOLD guidelines is the inclusion of the Tdap vaccination.

Kandeil et al conducted a systematic review across multiple countries, including North America, to investigate the potential value of a booster vaccination against pertussis in older adults.[6] The review discussed that pertussis can lead to complications such as pneumonia as well as exacerbation in patients with COPD. The burden of pertussis is underestimated in older adults, and vaccination is therefore underutilized. A pertussis booster was found to be immunogenic, cost-effective, and well-tolerated. This review concluded that the pertussis vaccine can lower the disease burden and prevent transmission in more vulnerable populations.

One major role a pharmacist can take in supporting patients with COPD is providing education on self-management, medication adherence, and proper inhaler technique. A personalized written action plan that includes avoidance of aggravating factors, how to monitor or manage worsening symptoms, and breathlessness and energy-conservation techniques may be beneficial. Monitoring should include worsening of COPD symptoms, decline in spirometry results, smoking status, and number and frequency exacerbations. With an increased use of telemedicine and lack of face-to-face appointments during the COVID-19 pandemic, community pharmacists can have a larger impact on patient self-management and counseling.