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For Primary Care| Implementing guidelines

The 2023 GOLD Report: What’s New for Primary Care?

Dr Kevin Gruffydd-Jones Explores the Latest Recommendations from GOLD on the Diagnosis and Management of Chronic Obstructive Pulmonary Disease

Read This Article to Learn More About:
  • what to consider in a routine review for chronic obstructive pulmonary disease (COPD)
  • management of COPD based on the new, simplified ‘ABE’ severity stratification system
  • how to respond to acute exacerbations of COPD.
Key points and implementation actions for integrated care systems and clinical pharmacists in general practice can be found at the end of this article.

Implementation actions for clinical pharmacists in general practice and integrated care systems can be found at the end of this article.

Reflect on what you have learned from this article and test your knowledge with test-and-reflect patient scenarios on this topic

Chronic obstructive pulmonary disease (COPD) has an estimated global prevalence of one in 10 adults, and it is one of the three most common causes of death worldwide—in 2012, the condition accounted for more than 3 million deaths.1 The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has been producing evidence-based reports since 2001 that provide comprehensive advice on best practice for the diagnosis, management, and prevention of COPD.1 Unlike NICE guidelines, the GOLD report does not examine cost effectiveness. The scientific committee is largely secondary-care based, but the report is updated annually (in contrast, the NICE COPD guideline was last updated in 20192). As a result, many of the new recommendations are implemented in UK practice while NICE waits to catch up.

This article will examine the changes most relevant to UK primary care in the 2023 GOLD report. 

Definition and Diagnosis

The 2023 GOLD report redefines COPD as ‘a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction.'1

In practice, a diagnosis of COPD is made on the basis of:1

  • characteristic symptoms (chronic cough and dyspnoea with or without sputum production), particularly in those with a history of exposure to COPD risk factors
  • a postbronchodilator forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7.
A physical examination and chest X-ray are also warranted; although not diagnostic, these may help to exclude alternative pathologies and comorbidities.1

History Taking

Traditionally, COPD was considered a disease connected with exposure to tobacco smoke; however, it is estimated that half of all cases of COPD worldwide have other causes.1,3 Even in high-income countries, up to 30% of cases of COPD are thought to be due to risk factors unrelated to smoking,1,3,4 such as those outlined in Table 1.1

Table 1: Risk Factors to Consider in a Patient History1 

Risk FactorExamples
Exposure to tobacco smoke Primary or second-hand exposure, including as a result of use of recreational drugs 
Indoor pollutionIncomplete combustion from wood burners, gas appliances 
External pollutionPast or present exposure to vehicle pollution or industrial pollution 
OccupationExposure to vapours (e.g. pesticides), dusts, asbestos
Poor early life lung growthLow birth weight/prematurity, parental smoking (especially in utero), recurrent early life infections 
AsthmaPast or current wheezing, family or past history of atopy

History taking should involve looking for any ‘red flags’, such as weight loss or haemoptysis, that may suggest an alternative diagnosis of lung cancer or tuberculosis (TB).1,5,6 The presence of recurrent purulent sputum should raise suspicion of bronchiectasis or TB (in patients at high risk).1 Symptoms of significant comorbidities—such as ischaemic heart disease, gastro-oesophageal reflux, or rhinitis—should be elicited.1,7


Physical examination is an important element of standard care, but is unlikely to be diagnostic of COPD, as physical signs are unusual until lung function is significantly impaired.1 Some signs (such as cyanosis and lung hyperinflation) are suggestive of, but not specific to, COPD.1 Examination should be carried out to check the health of the respiratory and cardiovascular systems, and a general examination should be conducted to look for signs of anaemia, finger clubbing, and weight loss, which may suggest an alternative diagnosis.1,8,9


Postbronchodilator spirometry is required to establish a diagnosis of COPD.1,2 Although the GOLD report recommends the use of forced spirometry,1 accurate readings may not be possible in some patients—for example, patients who are frail or elderly—and quality-assured, relaxed readings are generally accepted as a viable alternative. For further information on how to conduct quality-assured spirometry (incorporating changes necessitated by the COVID-19 pandemic), see guidelines from the Association for Respiratory Technology and Physiology10 and the Primary Care Respiratory Society.11

All patients should have a chest X-ray to help exclude an alternative lung pathology, and a full blood count to exclude anaemia and check their eosinophil count (which may guide future treatment choices; see the section The Role of Blood Eosinophils).1

Sputum analysis may be warranted if there is a suspicion of TB or bronchiectasis,1 and an electrocardiogram/beta-natriuretic peptide analysis should be arranged if there is suspicion of cardiovascular disease.12,13

Management of Stable Disease

The key aims of the management of ‘stable’ COPD are to:1

  • reduce symptoms, including improving exercise tolerance and health status 
  • reduce future risks of exacerbations, disease progression, and mortality.
In 2011, the GOLD report14 classified COPD into four categories (ABCD) to guide pharmacotherapy according to the severity of symptoms, as measured using the modified Medical Research Council Dyspnoea Score (mMRC; the original MRC Dyspnoea Scale15 plus 1) or the COPD Assessment Test™ (CAT™)16 in addition to considering exacerbation frequency and whether those exacerbations were moderate or severe. ‘Moderate’ exacerbations are those defined as those not requiring hospital admission, and ‘severe’ exacerbations as those requiring admission in the preceding 12 months.

The 2023 GOLD report simplifies these categories as follows:1 

  • Group A—mMRC 0–1 or CAT™ <10; 0 or 1 moderate exacerbations in the preceding 12 months
  • Group B—mMRC ≥2 or CAT™ ≥10; 0 or 1 moderate exacerbations in the preceding 12 months
  • Group E—≥1 severe exacerbation leading to hospitalisation or ≥2 moderate exacerbations in the preceding 12 months, irrespective of symptom score.
Determining the proper management strategy requires routine review in primary care. Table 2 outlines the key elements of this review, which should be carried out at least annually, and subsequent nonpharmacological management.1

Table 2: Elements of Routine Primary Care Review and Nonpharmacological Management1,17

Factor to Be ReviewedComment
Symptoms (mMRC or CAT™ Score) If mMRC ≥2 or CAT™ Score ≥10, refer for pulmonary rehabilitation (see Pharmacological Management)
Exacerbation historyCheck that a self-management plan has been issued (see Pharmacological Management)
Smoking statusEncourage smoking cessation
Risk factors, including occupationIdentify risk factors that could be avoided
Inhaler technique and adherenceIf necessary, optimise technique and encourage adherence
Exercise level and pulmonary rehabilitationIf appropriate, refer to secondary care 
Self-managementCheck that an action plan has been discussed; provide or signpost to educational materials
Vaccination statusOne-off pneumococcal vaccination; annual COVID-19 and influenza vaccines
Annual FEV1 measurementsHand-held spirometry will serve to monitor lung-function deterioration
Pulse oximetryRefer for oxygen assessment if two readings 3 weeks apart are ≤92%
BMIConsider dietary referral if <20 mg/kg2
ComorbiditiesTreat as per national guidelines
Anxiety or depressionConsider use of NICE screening questions[A]
Social supportWho is the principal carer? (if appropriate)
[A] NICE screening questions for use in chronic disease:17
  • ‘During the last month have you often been feeling down, depressed or hopeless?'
  • ‘During the last month have you been bothered by having little pleasure or interest in doing things?’
mMRC=modified Medical Research Council Dyspnoea Sale; CAT™=COPD Assessment Test™; FEV1=forced expiratory volume in 1 second; BMI=body mass index 

Pharmacological Management 

There are major changes in the 2023 GOLD report concerning pharmacotherapy.1 Initial pharmacotherapy is based on the ‘ABE’ categorisation, as explained in Table 3.1 

Table 3: Initial Pharmacotherapy for COPD (Adapted for the UK from GOLD1)

GroupExacerbations in the Preceding 12 MonthsSymptom ScoreTherapy[A]
A0 or 1 moderate exacerbationsmMRC 0–1, CAT™ <10Bronchodilator, preferably regular long acting
B0 or 1 moderate exacerbationsmMRC ≥2, CAT™ ≥10LABA/LAMA combination
E≥2 moderate exacerbations or ≥1 severe exacerbation leading to hospitalisationIrrespective of symptomsLABA/LAMA combination. If blood eosinophils ≥300 cells/mcl, consider LABA/LAMA/ICS combination
[A] A SABA should be provided for immediate relief of symptoms
COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease; mMRC=modified Medical Research Council Dyspnoea Scale; CAT™=COPD Assessment Test™; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid; SABA=short-acting beta2 agonist
Unlike the NICE guideline,2 the GOLD report recommends that, when an inhaled corticosteroid (ICS) is indicated, this should be prescribed as a long-acting beta2 agonist (LABA)/long-acting muscarinic antagonist (LAMA)/ICS triple inhaler rather than as part of dual LABA/ICS therapy—this is because LABA/LAMA/ICS triple therapy has demonstrated superior efficacy in reducing exacerbations and lowering mortality compared with dual LABA/ICS therapy.1,18,19The NICE guideline adds that an ICS/LABA should be prescribed for patients with coexisting asthma, whereas GOLD does not suggest any specific therapy for patients with suspected or diagnosed comorbid asthma, and recommends treating them in line with local asthma guidance.1,2

The Role of Blood Eosinophils

The GOLD report emphasises the use of blood eosinophils in judging whether to initiate an ICS.1 A retrospective analysis of several large randomised controlled trials showed that there was little additional benefit of triple therapy compared with dual bronchodilator therapy if a patient’s blood eosinophil count was less than 100 cells/mcl, but that there was maximal effect if their blood eosinophil count was greater than 300 cells/mcl.20,21 The risk of pneumonia with ICS use is greatest in patients with a blood eosinophil count of less than 100 cells/mcl.1

Historic blood eosinophil levels can be used for this purpose, although it is important to note that these may have been affected if the patient was experiencing an acute exacerbation or taking oral steroids at the time of measurement.1 The results are reproducible, especially if the blood eosinophil count is less than 100 cells/mcl, but measurements may need to be repeated if it has ever been over 300 cells/mcl. 

Add-On Pharmacotherapy 

If a patient continues to experience dyspnoea and/or exacerbations, then the following should be checked before stepping up therapy:

  • adherence and inhaler technique1
  • that the continued symptoms are due to COPD and not a comorbidity (for example, lung cancer)1
  • whether nonpharmacological treatment, including avoidable triggers, has been optimised.

Figure 1 summarises the primary-care implementation of GOLD recommendations for add-on therapy.1

As with initial therapy, and in line with NICE guidance, ICS-containing therapy should be prescribed for patients with coexisting asthma.1

Figure 1: Add-on Pharmacotherapy1

Figure 2 Add-on pharmacotherapy algorithm
eos=eosinophil; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid


Management of Acute Exacerbations

An acute exacerbation of COPD (also called an ‘ECOPD’ in the GOLD report) is defined as ‘an event characterized by increased dyspnea and/or cough and sputum that worsens in <14 days which may be accompanied by tachypnea and/or tachycardia.’1 The main trigger for exacerbations is viral infection, but bacterial infection, environmental pollution, and occupational factors can also initiate or amplify exacerbations.1 

Recovery from an acute exacerbation can take 4–6 weeks, but 20% of patients still have symptoms after 8 weeks; not all patients will return to a pre-exacerbation functional state.1 The main features of exacerbation management in primary care consist of an assessment followed by appropriate treatment.1 


It is important to establish the diagnosis. Symptoms of an acute exacerbation of COPD may also be present in other conditions—for example, pneumonia, pulmonary embolism, and acute heart failure—so history taking and examinations should be directed to exclude these.1 

The severity and potential need for admission can be determined using the criteria in Table 4.1

Table 4: GOLD Thresholds for Severity of Acute Exacerbations1

SeverityDyspnoea VAS ScoreRR (breaths/min)HR (beats/min)Resting SaO2CRP (mg/l)ABG
Mild<5<24<95≥92%[A] and a change ≤3% if known<10

Moderate (meeting at least three of these criteria)≥5≥24≥95<92%[A] and/or a change >3% if known≥10If obtained, may show hypoxaemia (PaO2 ≤60 mmHg) and/or hypercapnia (PaCO2 >45 mmHg) but no acidosis
Severe≥5≥24≥95<92%[A]≥10Shows new onset/worsening hypercapnia and acidosis (PaCO2 >45 mmHg, pH <7.35)
[A] Breathing ambient air (or patient’s usual oxygen prescription)
GOLD=Global Initiative for Chronic Obstructive Lung Disease; VAS=Visual Analogue Dyspnoea Scale; RR=respiratory rate; HR=heart rate; SaO2=oxygen saturation; CRP=C-reactive protein; ABG=arterial blood gas; PaO2=partial arterial pressure of oxygen; PaCO2=partial arterial pressure of carbon dioxide

Management in Primary Care

Management of exacerbations in primary care should include pharmacological intervention, assessment of social circumstances, and timely follow up.1


The initial treatment for dyspnoea is one or two puffs of a short-acting bronchodilator given via a large volume spacer every hour for two or three doses, then every 2–4 hours until symptoms improve.1 For most patients, there is no advantage to delivering a bronchodilator via a nebuliser, unless they are unable to manage sufficient inspiratory effort or they are on maintenance nebuliser therapy.1

Oral Steroids

Oral steroids reduce the duration of the exacerbation, and lessen the risk of relapse.1 A dose of 40 mg prednisolone per day for a maximum of 5 days is recommended (longer courses increase the risk of pneumonia).1 

Oral Antibiotics

A 5-day course of oral antibiotics is recommended for patients who have increased sputum purulence and one (or both) of the following:1

  • increased dyspnoea 
  • a sputum volume indicative of potential bacterial infection. 
The GOLD report recommends oral tetracycline (for example, doxycycline 200 mg immediately, followed by 100 mg once daily)1,2 or a macrolide (for example, clarithromycin 500 mg twice daily) as first-line antibiotics. This is in line with NICE recommendations; however, NICE also recommends amoxicillin 500 mg three times a day first line,22 whereas GOLD recommends an aminopenicillin (practically, in the UK this would be amoxicillin) plus clavulanic acid, a macrolide, or a tetracycline.1

Social Care

This is a notable omission among the recommendations for acute exacerbations in the report. It is important to ensure that acutely unwell patients have adequate home support, that both the patient and any carers have clear instructions in the event that the patient’s condition deteriorates, and that the patient is followed up. 

Follow Up

Patients managed acutely in primary care should be followed up at an early stage according to clinical need. All patients should be fully reviewed within 4 weeks of being treated for a COPD exacerbation.1 A comprehensive review should be carried out as per the routine review (see Table 2), but with special reference to the prevention of further exacerbations.1 All hospitalised patients should have their vitamin D levels checked and supplemented if they are deficient in order to reduce the risk of further exacerbations.1


COVID-19 can be an important viral trigger for an acute exacerbation of COPD, and should be considered when there is an acute worsening of cough and/or dyspnoea. Patients with COPD who develop COVID-19 infection report excessive tiredness, diarrhoea, and dyspnoea more often than those without COPD.1

In the presence of COVID-19 restrictions, remote COPD reviews can be undertaken for many patients.1 There is no evidence of increased harm compared with face-to-face review, but in-person review may be more appropriate for patients with:1

  • communication difficulties
  • need for immediate attention for severe medical symptoms
  • treatment needs that require in-person attendance
  • changes in symptoms necessitating a differential diagnosis work-up that requires a physical exam and/or testing.
It is important for patients to be encouraged to exercise regularly during any lockdown.1 Home-based pulmonary rehabilitation can be offered, but is likely to be less effective than supervised, face-to-face therapy.1,23 All patients should be vaccinated against COVID-19.1

Barriers to Implementing the Strategy

In general, the GOLD recommendations are in line with NICE guidance.1,2 However, NICE advocates LABA/LAMA/ICS triple therapy second line to LABA/ICS or LABA/LAMA dual therapy,2 whereas GOLD recommends considering first-line triple therapy in patients with high blood eosinophils and a history of two or more moderate exacerbations, or one or more severe exacerbations, in the previous year.1 This lower threshold for using LABA/LAMA/ICS triple therapy may be questioned by local formulary committees, and the recommendation to use blood eosinophils to guide therapy may have additional resource implications. The use of historical blood eosinophil counts may lessen this problem though. 

There is evidence from a 2021 clinical audit of COPD and asthma in primary care in Wales that NICE- and GOLD-recommended diagnostic and review measurements are not being recorded routinely.24 This is an indication that there is an urgent need for national and local COPD review templates. 


COPD remains a cause of considerable mortality and morbidity worldwide and in the UK, and there is increasing recognition of nontobacco-related causes of the disease. 

In line with NICE’s 2019 guideline, GOLD’s updated 2023 strategy emphasises the importance of accurate diagnosis supported by postbronchodilator spirometry and nonpharmacological management. Inhaled bronchodilator therapy remains the cornerstone of pharmacological management, but the GOLD strategy has an increased role for triple LABA/LAMA/ICS therapy in patients with exacerbations, especially in the presence of a high blood eosinophil count. 

Management of an acute attack of COPD in primary care involves assessing the severity of the attack and the presence of any confounding acute respiratory or cardiac comorbidities, including the need for hospital admission. Therapy with high-intensity short-acting bronchodilators and oral steroids remains the gold standard of primary care management, with short-course oral antibiotics for patients with a change in sputum colour. 

Useful educational materials for patients with COPD can be obtained from Asthma and Lung UK.

Key Points
  • A diagnosis of COPD is made on the basis of characteristic symptoms (cough with or without sputum and dyspnoea) with a history of exposure to risk factors and confirmed by a postbronchodilator FEV1/FVC ratio of <0.7
  • Up to 30% of cases of COPD in high-income countries may be due to causes unrelated to tobacco smoking, such as occupation and exposure to outdoor or indoor pollution 
  • The key aims of management of stable COPD are to reduce symptoms and decrease the risks of future exacerbations, disease progression, and death
  • Review of stable patients should be performed at least annually and a record made of recent (within previous 12 months) exacerbation history, which is a major determinant of future risk
  • The cornerstone of pharmacological management is regular bronchodilator treatment 
  • Treatment with LABA/LAMA/ICS triple therapy should be considered for patients with a history of exacerbations, especially if there is coexisting asthma and a raised blood eosinophil count (≥300 cells/mcl)
  • Check inhaler technique, adherence, and diagnosis, and optimise nonpharmacological interventions, before stepping up pharmacotherapy
  • The initial treatment of an acute exacerbation of COPD in primary care is a high-intensity, short-acting bronchodilator delivered via a large-volume spacer combined with oral prednisolone 40 mg/day for 5 days; a 5-day course of oral antibiotics should be given if there is a change in sputum colour with increased sputum volume and/or increased dyspnoea
  • All patients should have a formal review within 4 weeks of hospitalisation or initial treatment of an acute exacerbation.
COPD=chronic obstructive pulmonary disease; FEV1=forced expiratory volume in 1 second; FVC=forced vital capacity; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid
Note: At the time of publication (March 2023), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.
Implementation Actions for ICSs

written by Dr David Jenner, GP, Cullompton, Devon

The following implementation actions are designed to support ICSs with the challenges involved in implementing new guidance at a system level. Our aim is to help you to consider how to deliver improvements to healthcare within the available resources.

  • Review local COPD formulary choices and management guidance in light of this update
  • Compare this guidance with current NICE guidance, which includes cost effectiveness as part of its remit, when updating local care pathways and formularies
  • Define specific indications and roles for inhaled corticosteroids in the management of COPD, as they have the potential to increase cases of pneumonia if used inappropriately
  • Ensure that there is prompt access to local quality-assured spirometry, pulmonary rehabilitation, and smoking-cessation services, with the necessary adaptations to procedures in light of the COVID-19 pandemic.
ICS=integrated care system; COPD=chronic obstructive pulmonary disease
Implementation Actions for Clinical Pharmacists in General Practice

Written by Shivangee Maurya, Clinical Services Pharmacist, Soar Beyond Ltd 

The following implementation actions are designed to support clinical pharmacists in general practice with implementing guidance at a practice level.

According to the World Health Organization, COPD is the third-leading cause of death worldwide, despite being a preventable and treatable condition.[A] This statistic highlights the importance of clinical pharmacists in general practice playing their part in addressing the burden of COPD. The 2023 revision of the GOLD report includes new and updated recommendations relevant to clinical pharmacists that aim to improve the development and implementation of effective management programmes, as well as provide approaches to the prevention, early identification, and treatment of COPD.[B]

Clinical pharmacists can undertake the following key actions in general practice to ensure implementation of the 2023 GOLD report updates:[C]

  • identification—ensure that patients categorised by the GOLD update as ‘pre-COPD’ or ‘PRISm’ are identified early, as there is an opportunity for prevention, early diagnosis, and prompt and appropriate therapeutic intervention
  • assessment—familiarise yourself with the new GOLD ABE assessment tool (still to be validated by appropriate clinical research)
  • diagnosis—when seeing patients acutely for potential COPD exacerbations, consider other causes of their symptoms
  • treatment—review the positioning of LABA/LAMA, LABA/ICS, and triple therapy for patients with COPD and how this may impact your approach when reviewing patients; recommendations on initial pharmacological treatment have also been updated in line with the ABE assessment tool
  • counselling—when initially explaining what COPD is to patients, use the updated GOLD definition for COPD: ‘Chronic obstructive pulmonary disease … is a heterogeneous lung condition characterized by chronic respiratory symptoms (dyspnea, cough, sputum production, and/or exacerbations) due to abnormalities of the airways (bronchitis, bronchiolitis) and/or alveoli (emphysema) that cause persistent, often progressive, airflow obstruction’
  • share and cascade—send around the updated report, provide a summary of key changes to be implemented in clinical practice, and discuss these at your next clinical meeting; also, find out if your local COPD guideline is going to be revised to include any of the GOLD updates.

The i2i Network has a suite of training and implementation resources—both bespoke and free—for clinical pharmacists in general practice, including e-learning and on-demand training delivered by experts and covering a range of long-term conditions, including COPD. Become a free i2i Network member at

[A] World Health Organization website. Chronic obstructive pulmonary disease (COPD). (accessed 14 March 2023).
[B] Global Initiative for Chronic Obstructive Lung Disease. GOLD 2023 key changes summary. Fontana, WI, USA: GOLD, 2023. Available at: 
[C] Global Initiative for Chronic Obstructive Lung Disease. Global initiative for chronic obstructive lung disease. Fontana, WI, USA: GOLD, 2023. Available at: 

COPD=chronic obstructive pulmonary disease; GOLD=Global Initiative for Chronic Obstructive Lung Disease; PRISm=preserved ratio impaired spirometry; LABA=long-acting beta2 agonist; LAMA=long-acting muscarinic antagonist; ICS=inhaled corticosteroid