Key Topics in 2025 GOLD Report Include CVD Risk, Spirometry

Comparison measures of lung function and improved categorization of cardiovascular disease (CVD) risk were among the key updates to the 2025 report from the Global Initiative for Chronic Obstructive Lung Disease (COPD) (GOLD).

Spirometry information now includes more comprehensive information on lower limit of normal (LLN), z-scores, and reference values, said Claus F. Vogelmeier, MD, of the Philipps-University of Marburg, Marburg, Germany, in a presentation of the report at the 2024 GOLD International COPD Conference.

Race-corrected reference values may have important consequences for patients, Vogelmeier noted. He referenced data from a study in The New England Journal of Medicine showing that race-neutral or adjusted values may affect clinical outcomes.

Although questions remain about the validity of the GLI-Global equations given their lack of consideration of population differences, the new GOLD Report continues to recommend their use as the reference standard to assess lung function impairment, Vogelmeier said.

A chart included in the report compares fixed ratio and LLN; although fixed ratio is simple and established, there is a risk for overdiagnosis in older adults, said Vogelmeier. By contrast, LLN relies on reference values.

COPD should be considered in any patient with dyspnea, chronic cough or sputum production, and/or a history of exposure, and pre-bronchodilator measures spirometry showing a post-bronchodilator FEV1/FVC

The CT section of the report also has been updated to address the use of CT imaging, with new details on its use for detecting emphysema, lung nodules, and COPD-associated morbidities, Vogelmeier said.

Added Sections Address CVD, Climate

CVD risk is now covered in a new section of the GOLD Report, Vogelmeier said in his presentation. “It may play a major role during and after acute exacerbations,” he noted.

Climate change and COPD have their own section, based on consistent data from population studies showing an increased risk for death among individuals with COPD after exposure to extremes of heat and cold, Vogelmeier said. Data also indicate associations between increased temperatures and COPD hospitalizations and between decreased temperatures and COPD exacerbations, he added.

Follow-up pharmacologic updates include new information about the use of ensifentrine and dupilumab, Vogelmeier said. He emphasized data from the recent ENHANCE-1 and ENHANCE-2 studies in which ensifentrine significantly reduced the time to first exacerbation in patients with COPD compared with placebo.

As an anti-inflammatory therapy for patients with stable COPD, ensifentrine has been shown to improve lung function, but data on patients at increased exacerbation risk are lacking, he said.

The updated information also advises clinicians to consider adding ensifentrine for patients who remained symptomatic despite long-acting beta-2 agonists (LABAs) plus long-acting muscarinic antagonists (LAMAs), Vogelmeier said. As for dupilumab, data support its use for reducing exacerbations and improving lung function and quality of life in patients with moderate to severe COPD and a history of exacerbations, chronic bronchitis, and blood eosinophil counts ≥ 300 cells/µL. The report updates guidance on withdrawal of inhaled corticosteroids (ICS) and suggests considering changing patients to LABA + LAMA if they are on LABA + ICS with no relevant exacerbation history or have blood eosinophils

Finally, pulmonary hypertension has its own section in the new report, which defines it as a mean pulmonary arterial pressure > 20 mm Hg. Patients with pulmonary hypertension and COPD should be referred to a pulmonary hypertension center, and long-term oxygen therapy is recommended for hypoxemic patients. However, patients with COPD and pulmonary arterial hypertension or pulmonary hypertension associated with pulmonary artery obstruction can be managed according to the 2022 ESC/ERS pulmonary hypertension guidelines.

Key GOLDen Takeaways

“Clinicians will find the sections on the newly approved biologics helpful to determine which patients may benefit from these new therapies,” said Gerard J. Criner, MD, chair and professor of thoracic surgery at the Lewis Katz School of Medicine at Temple University, Philadelphia, in an interview.

Information on ensifentrine also may help clinicians determine which patients may benefit, he added.

The updated approach to spirometry, with a fixed ratio to identify patients with obstruction, the reasons why, and the relationship of race neutral reference standards, will be valuable to clinicians, Criner told Medscape Medical News. The new guidance should simplify and expand the use of spirometry, so it becomes more of a central noninvasive diagnostic test to inform further diagnostic tests and treatment of patients with COPD.

“Ideally, the new section of screening for COPD in targeted populations will expand the use of lung cancer screening to be coupled with spirometry and symptoms assessment to diagnose COPD earlier,” Criner told Medscape Medical News. Clinicians can then start appropriate treatment for patients in these populations who are symptomatic but have been underdiagnosed and, as a result, untreated for their COPD, he said.

In clinical practice, none of the updated guidelines in the new GOLD Report are difficult to implement, said Criner. However, “Based on the patient’s insurer and plan, clinicians may need to help patients with issues getting their therapy or diagnostic tests approved and help expand patients’ access to the tests and therapies to be implemented,” he noted.

Although this year’s report provides updated guidance, much more research is needed, Criner told Medscape Medical News.

Many new biological targets are currently being studied to treat and prevent exacerbations, with data expected in the next 6-24 months, he said. Other research gaps include the need for more potent treatments to alleviate breathlessness in COPD patients, more therapies to help with smoking cessation, more access to lung cancer screening for eligible individuals, and more studies on the impact of climate change on lung health, he added.

Vogelmeier disclosed serving as an advisor for Aerogen, AstraZeneca, CSL, Behring, GlaxoSmithKline, Grifols, Hoffman-LaRoche, Insmed, Menarini, Nuvaira, and Sanofi. He also disclosed serving as a speaker for Aerogen, AstraZeneca, CSL, Behring, Boehringer Ingelheim, GlaxoSmithKline, Hoffman-LaRoche, Insmed, MedUpdate, Menarini, Nuvaira, and Sanofi, as well as unrestricted grants from AstraZeneca, Boehringer Ingelheim, Chiesi, GlaxoSmithKline, Grifols, and Novartis.

Criner had no relevant financial conflicts to disclose.