COPD Diagnosis and Management: A Practical Guide to the GOLD Framework
Clinical Practice Update — ABE Classification, Eosinophil-Guided ICS, Triple Therapy, Biologics, and the 2026 Disease Activity Concept
This is an original clinical education article informed by current guidelines and evidence. See References below for source documents.
- Clinical Focus
- Spirometric diagnosis, ABE assessment, initial pharmacotherapy, eosinophil-guided ICS escalation, triple therapy, biologics for refractory COPD, and non-pharmacological management
- Target Audience
- Internists, primary care physicians, pulmonologists, residents, nurse practitioners, respiratory therapists
- Setting
- Primary care, pulmonary clinic, emergency department, hospital inpatient
- Source Evidence
- •GOLD 2025 Report — Global Strategy for Prevention, Diagnosis and Management of COPD (November 2024)
- •GOLD 2026 Report Update — Disease Activity Concept, Lowered Group E Threshold, Biologics Evidence
- •NICE Guideline [NG115] — Chronic Obstructive Pulmonary Disease in Over 16s (2018, updated 2019)
- •Key Trials: IMPACT (Triple Therapy, NEJM 2018), ETHOS (Triple Therapy, NEJM 2020), BOREAS (Dupilumab, NEJM 2023)
Key Clinical Takeaways
The most important actionable points from this Practice Update on COPD diagnosis and management, reflecting the GOLD 2025/2026 framework.
- 1Confirm COPD with post-bronchodilator spirometry: FEV1/FVC <0.7 is required. Pre-bronchodilator FEV1/FVC <0.7 is highly suggestive and can guide case-finding in primary care. → Making the Diagnosis
- 2Classify every patient using the ABE framework: symptoms (mMRC/CAT) and exacerbation history determine whether they are Group A, B, or E → ABE Classification
- 3Bronchodilators are foundational — start LAMA+LABA for most symptomatic patients. Unlike asthma, ICS is not first-line. → Initial Pharmacotherapy
- 4Check blood eosinophils — they guide ICS decisions: ≥300 cells/μL favours ICS addition; <100 cells/μL argues against ICS → The Role of Eosinophils
- 5Triple therapy (LAMA+LABA+ICS) reduces exacerbations and mortality versus dual bronchodilation in the right patients — the IMPACT and ETHOS trials confirmed this → Escalation to Triple Therapy
- 6The GOLD 2026 report lowers the Group E threshold to ≥1 moderate or severe exacerbation in the past year, signalling earlier treatment intensification → What Changed in GOLD 2026
- 7Dupilumab is the first biologic with evidence in COPD — for patients still exacerbating on triple therapy with eosinophils ≥300 and chronic bronchitis → Beyond Triple Therapy
- 8Smoking cessation remains the single most impactful intervention — pharmacotherapy doubles long-term quit rates → Non-Pharmacological Management
- 9Offer pulmonary rehabilitation to all symptomatic patients regardless of GOLD grade — it improves exercise capacity, dyspnoea, and quality of life → Non-Pharmacological Management
- 10Vaccinate all COPD patients: influenza, pneumococcal, COVID-19, RSV, and a single dose of Tdap if not previously received → Non-Pharmacological Management
How Should You Diagnose COPD?
COPD should be suspected in any adult over 35 with chronic dyspnoea, cough, or sputum production and a relevant exposure history (typically ≥20 pack-years of smoking, but also biomass fuel, occupational dust, or early-life respiratory events). Spirometry is essential — clinical features alone are insufficient to make the diagnosis.
Perform post-bronchodilator spirometry to confirm COPD. A fixed ratio of FEV1/FVC <0.70 after bronchodilator administration establishes the diagnosis of persistent airflow limitation. GOLD 2025 additionally emphasises that pre-bronchodilator FEV1/FVC <0.70 is highly indicative and can be used for case-finding where post-bronchodilator testing is not readily available.
Strong RecHigh EvidenceGOLD 2025Measure a blood eosinophil count (CBC with differential) at diagnosis. This is used later to guide ICS decisions, not to make the COPD diagnosis itself. Because eosinophils are genetically stable, a single measurement is usually sufficient.
Strong RecModerate EvidenceGOLD 2025Check alpha-1 antitrypsin level in patients diagnosed at a young age (<45), those with a strong family history, or those with severe disease disproportionate to exposure history. This is a once-in-a-lifetime test.
Strong RecModerate EvidenceGOLD 2025Do not routinely use bronchodilator reversibility testing to make therapeutic decisions. Reversibility in COPD is variable and does not reliably predict response to bronchodilators or ICS.
AgainstModerate EvidenceGOLD 2025Which Patients Get Which Initial Treatment?
Initial pharmacotherapy is determined by the GOLD ABE classification, which was introduced in the 2023 revision and carried forward into GOLD 2025 and 2026. It replaces the former ABCD scheme by merging groups C and D into a single Group E (for “exacerbation”) to underscore that exacerbation history drives treatment intensity regardless of symptom burden.
Initial Pharmacotherapy by ABE Group: A Practical Decision Guide
| Group | Criteria | Initial Treatment | Eosinophil Consideration | Practical Tips |
|---|---|---|---|---|
| A | Low symptoms (mMRC 0–1 or CAT <10) + 0–1 moderate exacerbations, no hospitalisation | A single bronchodilator: LAMA or LABA | Not relevant at this stage | LAMA preferred if any exacerbation risk — tiotropium has the strongest evidence. Can use LABA if LAMA not tolerated. |
| B | High symptoms (mMRC ≥2 or CAT ≥10) + 0–1 moderate exacerbations, no hospitalisation | Dual bronchodilation: LAMA + LABA (preferably single inhaler) | Not relevant at this stage | Most newly diagnosed symptomatic patients fall here. Single-inhaler LAMA/LABA improves adherence. |
| E | Any symptom burden + ≥2 moderate exacerbations OR ≥1 hospitalisation in past year (GOLD 2025). GOLD 2026 lowers to ≥1 moderate or severe exacerbation. | LAMA + LABA. Consider LAMA + LABA + ICS if eosinophils ≥300 cells/μL. | Eos ≥300: start with triple therapy. Eos <300: start with LAMA+LABA, add ICS later if exacerbations persist and eos ≥100. | These patients need aggressive early treatment. Check inhaler technique and adherence at every visit. |
- Prescribe rescue short-acting bronchodilators (SABA or SAMA) for all patients for immediate symptom relief.
- LABA+ICS without a LAMA is not recommended as initial therapy in COPD — always include a LAMA when ICS is used.
When and How Should You Escalate Treatment?
Escalation decisions are driven by two questions: Is the patient still symptomatic? Is the patient still exacerbating? Blood eosinophils determine whether ICS is the right escalation or whether non-ICS strategies (azithromycin, roflumilast) are more appropriate.
Escalate to LAMA+LABA+ICS (triple therapy) for patients on LAMA+LABA who continue to exacerbate and have blood eosinophils ≥100 cells/μL. Evidence strongly favours ICS addition when eosinophils are ≥300 cells/μL.
Strong RecHigh EvidenceGOLD 2025IMPACT 2018ETHOS 2020For patients on LAMA+LABA who continue to exacerbate but have blood eosinophils <100 cells/μL, do not add ICS. Instead, consider adding azithromycin (in non-smokers) or roflumilast (if FEV1 <50% predicted and chronic bronchitis phenotype).
Moderate RecModerate EvidenceGOLD 2025Consider dupilumab as add-on to triple therapy for patients who continue to exacerbate, have blood eosinophils ≥300 cells/μL, and a chronic bronchitis phenotype. The BOREAS and NOTUS trials showed approximately 30% reduction in moderate-to-severe exacerbations with improved lung function.
Moderate RecModerate EvidenceGOLD 2025BOREAS 2023Avoid withdrawing ICS in patients with blood eosinophils >300 cells/μL due to the increased risk of exacerbations. ICS withdrawal may be considered in clinically stable patients with infrequent exacerbations and eosinophils <300, with gradual tapering and close monitoring.
Strong RecModerate EvidenceGOLD 2025Clinical Decision Pathway
Monitoring and Follow-Up
| Parameter | When | Why It Matters | Common Pitfalls |
|---|---|---|---|
| Spirometry | At least annually | Identifies rapid decliners (>40 mL/year FEV1 loss) who may need treatment intensification | Not performing annual spirometry — many patients are only tested at diagnosis |
| Symptom assessment (mMRC/CAT) | Every visit | Tracks symptom trajectory and guides treatment adjustment | Relying on clinician impression instead of validated tools |
| Exacerbation history | Every visit | Determines ABE group and escalation decisions | Patients underreport exacerbations — ask specifically about courses of oral steroids or antibiotics |
| Inhaler technique | Every visit | Poor technique is the most common correctable cause of treatment failure | Assuming the patient knows how to use their inhaler — demonstrate and check back every time |
Evidence in Context
What Changed From GOLD 2025 to GOLD 2026?
The 2026 report lowers the Group E exacerbation threshold from ≥2 moderate or ≥1 severe to ≥1 moderate or severe exacerbation in the past year. It formally introduces “disease activity” as a therapeutic target, recognising that achieving a low-activity state improves prognosis. A new chapter on artificial intelligence in COPD detection and management was added. Evidence supporting biologics (dupilumab, mepolizumab) is now presented in a dedicated figure.
Where GOLD and NICE Agree and Differ
Agreement: Both use the fixed ratio FEV1/FVC <0.70 for diagnosis, recommend LAMA+LABA as first-line for symptomatic patients, emphasise smoking cessation and pulmonary rehabilitation, and support ICS escalation guided by eosinophils and exacerbation frequency.
Differences: NICE NG115 uses a slightly different classification and suggests considering asthma-COPD overlap more explicitly. NICE recommends LAMA+LABA+ICS when asthma features or steroid responsiveness are suspected, whereas GOLD ties ICS decisions more tightly to eosinophil thresholds. NICE does not yet include guidance on biologics (dupilumab) or ensifentrine.
The Trials Behind Triple Therapy and Biologics
The IMPACT trial (2018) randomised over 10,000 patients and showed that fluticasone furoate/umeclidinium/vilanterol (triple therapy) reduced moderate-to-severe exacerbations by 25% versus LAMA+LABA and by 15% versus LABA+ICS. ETHOS (2020) confirmed these findings with budesonide/glycopyrrolate/formoterol, showing a 24% reduction versus LAMA+LABA and a signal towards reduced all-cause mortality. Both trials enrolled patients with a history of exacerbations and roughly 40% had elevated eosinophils. BOREAS (2023) was the first trial to show a biologic reduces COPD exacerbations — dupilumab reduced moderate-to-severe exacerbations by approximately 30% in patients with type 2 inflammation on triple therapy.
What We Still Don’t Know
References
- 1.Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for Prevention, Diagnosis and Management of COPD: 2025 Report. goldcopd.org/2025-gold-report/
- 2.Agustí A, Celli BR, Criner GJ, et al. Global Initiative for Chronic Obstructive Lung Disease 2023 Report: GOLD Executive Summary. Eur Respir J. 2023;61(4):2300239. doi:10.1183/13993003.00239-2023
- 3.Lipson DA, Barnhart F, Brealey N, et al. Once-Daily Single-Inhaler Triple versus Dual Therapy in Patients with COPD (IMPACT). N Engl J Med. 2018;378(18):1671–1680. doi:10.1056/NEJMoa1713901
- 4.Rabe KF, Martinez FJ, Ferguson GT, et al. Triple Inhaled Therapy at Two Glucocorticoid Doses in Moderate-to-Very-Severe COPD (ETHOS). N Engl J Med. 2020;383(1):35–48. doi:10.1056/NEJMoa1916046
- 5.Bhatt SP, Rabe KF, Hanania NA, et al. Dupilumab for COPD with Type 2 Inflammation Indicated by Eosinophil Counts (BOREAS). N Engl J Med. 2023;389(3):205–214. doi:10.1056/NEJMoa2303951
- 6.National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management [NG115]. 2018, updated 2019. nice.org.uk/guidance/ng115
How to Read the Evidence Tags
Every recommendation carries two tags. These are Medaptly’s own simplified interpretations for educational clarity.
Recommendation Strength
| Tag | Meaning | In Practice |
|---|---|---|
| Strong Rec | Benefits clearly outweigh risks. | Standard practice. |
| Moderate Rec | Evidence favours benefit. | Most patients should receive this. |
| Conditional Rec | Right choice depends on individual. | Shared decision-making. |
| Against | Risks outweigh benefits. | Avoid. |
Evidence Quality
| Tag | Meaning | Confidence |
|---|---|---|
| High Evidence | Multiple RCTs or meta-analyses. | Very confident. |
| Moderate Evidence | Single RCT or large observational studies. | Reasonably confident. |
| Low Evidence | Expert consensus or small studies. | May change. |
These are Medaptly’s simplified interpretations. Consult original documents in References for full details.