COPD management: GOLD ABE assessment and initial inhaler therapy

GOLD2026

ABE groups by symptoms (mMRC 0-1/CAT under 10 vs mMRC 2 or more/CAT 10 or more) and exacerbations. Initial inhaler: Group A, one long-acting bronchodilator; Group B, LABA plus LAMA; Group E, LABA plus LAMA, add ICS (triple) if blood eosinophils 300 or higher. Confirm with post-bronchodilator FEV1/FVC under 0.70.

GOLD2026

Group A/B: zero moderate or severe exacerbations in the prior year. Group E: one or more moderate or severe exacerbations (2026 lowered this threshold from the prior 2 or more, or 1 hospitalization). On follow-up, escalate to triple therapy if eosinophils 100 or higher with further exacerbations; avoid ICS if eosinophils under 100.

USPSTF2022Grade D

Do not screen asymptomatic adults for COPD (for example with screening spirometry or questionnaires). This does not apply to people with symptoms such as chronic cough, sputum, dyspnea, or wheezing, who should be evaluated, nor to very high-risk groups such as alpha-1 antitrypsin deficiency.

ATS2020Grade Strong (LABA/LAMA); conditional (others)

COPD with dyspnea or exercise intolerance: LABA plus LAMA over either alone (strong). If symptoms persist on LABA plus LAMA and there was one or more exacerbations in the past year needing antibiotics, oral steroids, or hospitalization, add ICS (triple therapy) (conditional). Consider withdrawing ICS from triple therapy after a year without exacerbations. Avoid maintenance oral corticosteroids even with frequent severe exacerbations. Opioids may be used for advanced refractory dyspnea despite optimal therapy (conditional).

ATS2023Grade Strong recommendation, moderate-quality evidence

Refer adults with stable COPD to pulmonary rehabilitation, and refer after any hospitalization for a COPD exacerbation. Center-based or telerehabilitation are both acceptable; supervised maintenance rehab after the initial program is optional (conditional).