GOLD guidelines 2011: what are the implications for primary care?

A major revision of the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines was published in December 2011, which takes account of the fact that chronic obstructive pulmonary disease (COPD) is a multi-system disease with effects on the patient beyond the effects of airflow limitation alone. The guidelines present a novel way of assessing the patient with COPD, linked to the major goals of stable COPD management of reducing symptoms (measured by the modified Medical Research Council Dyspnoea Score and/or COPD Assessment Tool) and reducing future risk (measured by the severity of airflow limitation and/or exacerbation history in the previous 12 months). Four patient groups are identified on the basis of their symptom/risk profile and a pharmacotherapy strategy is described using this profile. Emphasis is still placed on three pivotal features of non-pharmacological management: (1) reduction of exposure to risk factors (principally tobacco smoke); (2) promotion of exercise; and (3) immunisation against influenza and pneumococcal disease. In addition, there is a new chapter on the importance of assessing and treating co-morbid disease. The guidelines are a welcome advance in the management of COPD, but need further development to guide the more holistic approach to the management of patients with COPD in primary care.