1. GOLD Clasification Antonio Anzueto MD Professor Medicine University of Texas

2. Faculty Disclosures Non-commercial, non-governmental interests relevant to my presentation : Member of the ATS/ERS Task force on COPD and COPD Exacerbations, Current Member of Scientific Committee of GOLD, Current Personal financial interests in commercial entities that are relevant to my presentation: Boehringer Ingelheim: consultant: advisory board, Current GlaxoSmithKline: consultant, advisory board, Research Grant to the University, Current Chiesi: consultant, advisory board, Past Bayer-Schering Pharma: consultant, advisory board, Current Dey Pharma: consultant, advisory board, Current Forest laboratories: consultant, advisory board, Current

3. 2000- Staging of COPD: GOLD Guidelines I: Mild II: Moderate III: Severe IV: Very Severe FEV 1  80% With or without symptoms FEV 1 50 - 79% With or without symptoms FEV 1 30 - 49% With or without symptoms FEV 1 <30% Or presence of chronic respiratory failure or right heart failure Active reduction of risk factor(s); Influenza vaccination Add short-acting bronchodilator (when needed) Add regular treatment with one or more long-acting bronchodilators (when needed); Add rehabilitation Add ICS if repeated exacerbations Add long-term oxygen if CRF Consider surgical treatments

4. Agusti A et al. Respiratory Research 11 (1):122-136, 2010

5. GOLD - Goal of COPD Management Overall COPD Control Current ControlFuture Risk Symptoms Activity QoL Lung function Exacerbations Progression of the disease Mortality Medication adverse effects achievingreducing defined by GOLD 2011 www.goldcopd.org

6. Time for change Preventative: Tackle the root cause Approach: Fundamentally shift the way we treat COPD

7. GOLD Assessment Severity of Airflow Obstruction Worse obstruction More severe Exacerbations Frequent exacerbations D Severe Obstruction Severe Symptoms ++ Exacerbations High Risk Symptoms C Severe Obstruction Minimal Symptoms ++ Exacerbations A Mild-Mod Obstruction Minimal Symptoms Few Exacerbations B Mild-Mod Obstruction Severe Symptoms Few Exacerbations GOLD Website. http://www.goldcopd.com. Updated December 2012http://www.goldcopd.com

8. Do these groups exist ?

9. Frequency distribution of the four patient groups observed in the four studies Agusti et al ERJ 2013; 42:1391

10. Distribution of COPD types Johannessen et al. AJRCCM 2013; 188:51-59

11. GOLD Group Distribution % of Subjects GOLD Groups Agusti et al ERJ 2013; 42:1391 Haughney et al ERJ 2014; 43:993

12. Jones et al. ERJ 2013; 42: 647-654 Comparison of CAT and MRC

13. Assess risk of exacerbations

14. Risk of exacerbations Lange et al. AJRCCM 2012; 186; 975-981

15. Hurst et al. NEJM 2010; 363: 1128-38 Risk of exacerbations

16. Han et al. Lancet Infect Dis 2013; 1: 43-50 GOLD classification

17. GOLD Risk Categories using SGRQ Han et al Lancet Respiratory 2012

18. CT Scan Correlated: Emphysema COPD gene database A D B C

19. GOLD Stages: Microbiology by cultures and PCR during an Exacerbation % Patients GOLD Group Aydemir et al I J COPD 2014:9 1045–1051

20. Prognostic value

21. GOLD classification Soriano et al. Chest 2013; 143:694-702

22. GOLD classification Soriano et al. Chest 2013; 143:694-702 Mortality at 10 years follow-up of GOLD D COPD patients

23. Lange et al. AJRCCM 2012; 186: 975-981 GOLD classification

24. Mortality Distribution SPIROMETRIC RISK GOLD STAGE 1 &2 GOLD STAGE 3 & 4 GOLD STAGE 1 &2 GOLD STAGE 3 & 4 P Lange et al Am. J. Respir. Crit. Care Med.2012;186: 975-981

25. Agusti et al. ERJ 2013; 42: 636-646 Outcomes according to GOLD

26. ROC Mortality Risk: GOLD 2007 vs 2011 Johannessen et al. AJRCCM 2013; 188:51-59

27. Treatment

28. Agusti et al. ERJ 2013; 42: 636-646 Treatment according to GOLD Add ICS if exacerbations 1st choice: ICS+LABA or LAMA C: 70% FEV1<50% D: 63% FEV1<50%

29. GOLD D and B: HR Exacerbation Reduction ICS+ LABA vs LABA Anzueto et al ATS 2014

30. GOLD D Subgroups: HR Exacerbation Reduction ICS+ LABA vs LABA Anzueto et al ATS 2014

31. What do we know of the new GOLD classification   Prevalence of the four groups varied between populations.   Groups A and D – more stable over time   Hospitalization and Mortality lowest in A, highest D, similar B and C   Comorbidities – more prevalent and symptomatic in B and D   Exacerbations increases from A to D

33. GOLD is a dynamic process that Evolves with the disease

34. GOLD 2014: Antocholinergics 2013 2014 http://www.goldcopd.org/http://www.goldcopd.org/. Document 2014 Revision, Page 23

35. GOLD 2014: Anticholinergics – Adverse Events 20132014 2013 Tiospir study – clarify adverse eventos of Spiriva Respimat http://www.goldcopd.org/http://www.goldcopd.org/. Document 2014 Revision, Page 23

36. What we need next GOLD classification:   Phenotypes   Co-morbid conditions   Progression of disease – changes from one group to another   De-escalation of therapy

37. Different Look of COPD! Agusti A et al. Am J Respir Crit Care Med. 2011;184:(5):507-513.