GOLD 2024: a brief overview of key changes

1. Respiratory Institute, Clinic Barcelona, University of Barcelona, IDIBAPS, CIBERES, Spain

2. Department of Medicine, Pulmonary and Critical Care Medicine, University of Marburg, German Center for Lung Research (DZL), Marburg, Germany

Since 2001 (more than twenty years ago) the Global Initiative for Obstructive Lung Disease (GOLD) publishes and updates every year a document that recommends how to best diagnose and manage chronic obstructive pulmonary disease (COPD). 1 This is an enormous and continued team effort, so we want to start by acknowledging the dedication and hard work of all GOLD members through the years (www.goldcopd.org). The GOLD 2024 document has just been released and is available for free download in the GOLD website, together with a pocket guide and a teaching slide set. 2 Here we present a brief overview of what we think are the most relevant changes (or lack of) introduced in this 2024 edition of the GOLD recommendations.

To begin with, it is worth mentioning that, to avoid potential duplications and improve readability of the document, Chapter 3 (Evidence supporting prevention and maintenance therapy) and Chapter 4 (Management of stable COPD) in the GOLD 2023 document have now been merged into a single chapter (new Chapter 3 in GOLD 2024: Prevention and Management of COPD). Besides, the GOLD Science Committee identified a number of topics that, although already discussed in GOLD 2023, required and deserved further discussion. Accordingly, the following aspects about the diagnosis or management of COPD have been expanded and updated in GOLD 2024.

GOLD 2024 continues to propose that a post-bronchodilator FEV 1 /FVCOpen in a separate windowFigure 1Vaccination for stable COPD. Reproduced from GOLD 2024 with permission. 2

Traditionally the severity of exacerbations has been determined post-hoc based on the type and site of treatment received: mild if ambulatory with minimal therapeutic changes, moderate if antibiotics and/or systemic steroids were prescribed, and severe if the patient was hospitalized. This classification have been extensively used in many clinical trials as well as to classify stable patients in the A, B, or E groups to guide their initial pharmacologic treatment. 2 It is useless, however, to guide treatment at the point of care during an actual episode of exacerbation. Because of this, GOLD 2023 adopted the Rome proposal for the definition and assessment of severity of the episodes of exacerbation of COPD at the point of care based on a number of physiological biomarkers independently of the type or site of treatment. 26 GOLD 2024 continues to propose the use of the Rome classification to guide the treatment of the actual exacerbation episode but discusses (and hopefully clarifies) several aspects that deserve consideration: 1. it is necessary to separate the physiological classification of exacerbations (Rome proposal), intended to guide treatment at the point of care, from the site of care (outpatient, inpatient), which may be dictated by the clinical severity of the exacerbation but also by the structure of different health systems, availability of resources and/or personal/social conditions (e.g., living alone, comorbidities). In fact, GOLD 2024 now discusses several retrospective studies that confirm the validity of the Rome proposal to predict mortality but also showed that a substantial proportion of hospitalized patients had, according to Rome, mild exacerbations 27 , 28 ; 2. the classification of the stable patient in the A, B or E groups to guide initial pharmacologic treatment must still rely (by necessity) on the history recall of previous exacerbations which will have to be classified as moderate or severe by the site and type of treatment received.

As discussed above, the GOLD 2024 document discusses relevant aspects for the diagnosis, prevention, and management of COPD. Like GOLD has done over the last two decades, 1 it will continue to provide the different stakeholders interested in COPD, including patients, practicing clinicians and other health care professionals, basic science investigators, epidemiologists, pharma industry and payers, with the most updated and critically reviewed evidence on a yearly basis in order to improve the care for COPD patients and the distant goal of eventually eliminate COPD. 29

The authors acknowledge the work of Katie Lagerfeld (GOLD program Director) and Ruth Hadfield (medical writer) for their continued work to make possible the publication of the GOLD document every year.