A group of Mayo Clinic researchers has published an article recommending revisions to the existing Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2018 guidelines.

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Their article, “COPD Guidelines: A Review of the 2018 GOLD Report,” was published in the October 2018 issue of the Mayo Clinic Proceedings. In the article, researchers critique some parts of the current GOLD guidelines, specifically: fixed FEV1/FVC ratio, persistent symptoms, ABCD classification, overlooked comorbidities, asthma-COPD overlap syndrome, and electronic cigarette use.

Fixed FEV1/ FVC Ratio for Diagnosis

Researchers said there was evidence that the use of a fixed FEV1/FVC ratio of less than 0.70 contributes to over-diagnosis of obstruction in older subjects and under-diagnosis in younger subjects.

Instead they supported the ATS/ERS-recommended use the lower limit of normal for FEV1 to define the presence of obstruction.

Persistent Symptoms

Researchers believe further discussion is needed on the diagnostic requirement of persistent symptoms because it “risks under-identification of asymptomatic or intermittently symptomatic patients, which includes patients with moderate or even severe obstruction and frequent exacerbations, and who may be asymptomatic between exacerbations.”1

Some asymptomatic patients may be able to adapt their life to “mask” symptoms, such as less physical activity, researchers wrote.

ABCD Classification

Researchers believe that the familiar ABCD classification groups can be confusing and overwhelming to non-experts and they say recently published data show that this classification system does not predict all-cause and respiratory mortality more accurately than previous classifications.

“The new guide abandons the inclusion of a spirometric group as part of the sorting mechanism, but the fact remains that the coding and decoding required for groups ABCD does little to simplify the description of an individual patient,” they wrote.1 “For example, “Severe obstruction with severe symptoms and frequent exacerbations” is more readily understood than when encoded as “GOLD Stage 3D.”

“Although the 2017-2018 revision offers a more patient-centered approach to guiding pharmacotherapy, it remains imperfect and the pictorial representation is somewhat overwhelming.”


The current guidelines cover comorbidities but omit stroke and cancers (other than lung cancer), 11 of which are attributable to smoking. Examples include esophagus, larynx, bladder, cervix, oral cavity and throat, and more.

Asthma-COPD Overlap Syndrome

The 2018 guidelines do not adequately outline ACOS, the researchers wrote.

E-Cigarette Use

Researchers recommend GOLD to advise against the use of electronic cigarettes, due to “unconvincing evidence” of benefits, regulation concerns, and the potential for a gateway to smoking.

“Additional issues we suggest be addressed in future iterations include new and refined management strategies, review of novel pharmacotherapeutic options, further discussion of the asthma-COPD overlap phenotype, discussion of risks, benefits, and recommendations around e-cigarette use, and further guidance for referral for lung transplantation. We also hope that GOLD collaborates with major medical societies to achieve greater consensus-based guidance for the care of patients with COPD,” they concluded.