Editorial
The Rationale for GesEPOC in our Environment
El porqué de la GesEPOC en nuestro entorno
Aurelio Arnedillo Muñoz
UGC de Neumología, Alergia y Cirugía Torácica Hospital Universitario Puerta del Mar, Cádiz, Spain
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Exacerb.: exacerbation; FEV<span class="elsevierStyleInf">1</span>: forced expiratory volume in 1<span class="elsevierStyleHsp" style=""></span>s; ICS: inhaled corticosteroids; LABA: long-acting beta-agonists; LAMA: long-acting muscarinic receptor agonists; SABD: short-acting bronchodilators.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "José Luis Lopez-Campos, Eduardo Marquez-Martín, Francisco Ortega-Ruiz" "autores" => array:3 [ 0 => array:2 [ "nombre" => "José Luis" "apellidos" => "Lopez-Campos" ] 1 => array:2 [ "nombre" => "Eduardo" "apellidos" => "Marquez-Martín" ] 2 => array:2 [ "nombre" => "Francisco" "apellidos" => "Ortega-Ruiz" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0300289617301278" "doi" => "10.1016/j.arbres.2017.04.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0300289617301278?idApp=UINPBA00003Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1579212917301672?idApp=UINPBA00003Z" "url" => "/15792129/0000005300000006/v2_201707150125/S1579212917301672/v2_201707150125/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "The Rationale for GesEPOC in our Environment" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "293" "paginaFinal" => "294" ] ] "autores" => array:1 [ 0 => array:3 [ "autoresLista" => "Aurelio Arnedillo Muñoz" "autores" => array:1 [ 0 => array:3 [ "nombre" => "Aurelio" "apellidos" => "Arnedillo Muñoz" "email" => array:1 [ 0 => "aure152@separ.es" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "UGC de Neumología, Alergia y Cirugía Torácica Hospital Universitario Puerta del Mar, Cádiz, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El porqué de la GesEPOC en nuestro entorno" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) is one of the most important respiratory diseases, not only because it is both highly prevalent and highly underdiagnosed<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">1</span></a> (issues that still need to be addressed by pulmonologists), but also because of its enormous impact on quality of life and morbidity and mortality, particularly during exacerbations.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">2</span></a> In the 6 years since the Global Obstructive Lung Disease (GOLD) proposal was published in 2011, the criteria used to determine treatment have evolved rapidly. After a long period of little change, GOLD introduced the concept of evaluating dyspnea, quality of life, and risk of exacerbation, measured by lung function and the number of moderate-severe exacerbations in the previous year,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">3</span></a> to determine patient treatment.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The limited choice of drugs available until that time probably contributed to the previous lack of progress, but since then new bronchodilators, and in particular, combinations of these agents have appeared, and new studies focusing on the role of dual bronchodilation<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">4</span></a> and the combination of long-acting beta-2 agonists with inhaled corticosteroids (LABA<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>ICS)<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">5,6</span></a> have been published, dramatically changing the whole therapeutic framework to which we were bound for years.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Another factor that has definitively contributed to this rapid progress, and to the positioning of these molecules, is the introduction of COPD phenotypes.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">7</span></a> Spanish pulmonology has been a pioneer in this respect, thanks to the publication in 2012 of the Spanish COPD guidelines (GesEPOC),<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">8</span></a> which included clinical phenotypes in therapeutic regimens. This game-changing approach was later taken up by other countries in their national guidelines.</p><p id="par0020" class="elsevierStylePara elsevierViewall">GesEPOC introduced not only the concept of clinical phenotypes, but also provided a more complete evaluation of severity based on multidimensional scales (BODE or BODEx), leading to more personalized COPD treatment, although the downside was that patient management became more complex.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The complexity of applying these multidimensional scales for evaluating disease severity is clearly reflected in the analysis of the results of the EPOCONSUL study,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a> a clinical audit of over 4500 COPD outpatients conducted by Spanish pulmonologists. In this audit of almost 18,000 data entries, only 12.4% of respondents used BODE and 6.2% used BODEx to determine the severity of their COPD patients, compared to 81.3% who continued to use FEV<span class="elsevierStyleInf">1</span>, as they had been doing before GesEPOC and GOLD 2011.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Some criticism also emerged regarding the criteria required for classification of phenotypes. One example is the mixed phenotype or asthma COPD overlap syndrome (ACOS), which sometimes requires sputum eosinophilia determinations for diagnosis; this technique is not readily available in most centers, despite being proven in the literature to be one of the most consistent criteria.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">10</span></a> The difficulty of classifying patients according to their phenotype is also highlighted in the EPOCONSUL study, which found that phenotype classification was achieved in just under half of all patients.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Although the objective of the GesEPOC guidelines is more efficient COPD care in our setting, no objective information is available on the real impact of the proposal. It seems that specific tools need to be developed in the future to explore these issues, and in particular the difficulties reported in implementing the guidelines.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The new, revised and substantially altered GesEPOC guidelines<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">11</span></a> are published in this edition of our journal. One of the major changes is the simplified diagnosis of ACOS, with easily applied criteria based on current scientific evidence, requiring only clinical history, spirometry with bronchodilator challenge, and eosinophilia in peripheral blood,<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">12</span></a> features that will greatly facilitate patient classification, particularly in the primary care setting.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Another novel aspect is the stratification of patient risk. The complex classification of 5 severity stages based on multidimensional scales has been replaced by a simpler classification that differentiates “low-risk” patients, non-exacerbators according to GOLD 2017,<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">13</span></a> who have a modified Medical Research Council (mMRC) dyspnea grade 2 or less, and FEV<span class="elsevierStyleInf">1</span> greater than 50%, and “high-risk” patients, frequent exacerbators according to GOLD 2017, who have FEV<span class="elsevierStyleInf">1</span> less than 50% or mMRC dyspnea grade 3 or less. This classification simplifies the evaluation of the risk and treatment options, since low-risk patients will not need anti-inflammatory treatment and will only receive bronchodilators. The phenotype of high-risk patients will have to be identified, since the treatment of these patients will be selected according to whether they are non-exacerbators, ACOS, exacerbators with emphysema, or exacerbators with chronic bronchitis.</p><p id="par0050" class="elsevierStylePara elsevierViewall">These are only some of the innovations that appear in the new GesEPOC, which will be analyzed in more detail after publication.</p><p id="par0055" class="elsevierStylePara elsevierViewall">There is little doubt that the publication of the GesEPOC was a watershed in the management of COPD in Spain, and that it has been very influential, even beyond our borders. Both pharmacological and non-pharmacological therapeutic management of COPD have progressed rapidly in recent years. An update of the GesEPOC guidelines, responding to criticisms and reflecting new evidence, was required. The new GesEPOC will no doubt be the subject of much debate and discussion, and opinions will be aired that will enrich our perception of the disease and help us to continue our progress toward our future goal: providing our patients with ever more personalized, better quality care.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">14</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arnedillo Muñoz A. El porqué de la GesEPOC en nuestro entorno. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 40 | 21 | 61 |
| 2024 September | 38 | 14 | 52 |
| 2024 August | 57 | 36 | 93 |
| 2024 July | 36 | 23 | 59 |
| 2024 June | 50 | 22 | 72 |
| 2024 May | 73 | 30 | 103 |
| 2024 April | 38 | 22 | 60 |
| 2024 March | 36 | 16 | 52 |
| 2024 February | 24 | 24 | 48 |
| 2023 May | 1 | 0 | 1 |
| 2023 March | 3 | 4 | 7 |
| 2023 February | 28 | 24 | 52 |
| 2023 January | 18 | 28 | 46 |
| 2022 December | 48 | 27 | 75 |
| 2022 November | 44 | 23 | 67 |
| 2022 October | 39 | 40 | 79 |
| 2022 September | 22 | 29 | 51 |
| 2022 August | 34 | 49 | 83 |
| 2022 July | 26 | 45 | 71 |
| 2022 June | 21 | 42 | 63 |
| 2022 May | 32 | 33 | 65 |
| 2022 April | 29 | 29 | 58 |
| 2022 March | 32 | 44 | 76 |
| 2022 February | 27 | 30 | 57 |
| 2022 January | 26 | 38 | 64 |
| 2021 December | 32 | 41 | 73 |
| 2021 November | 34 | 39 | 73 |
| 2021 October | 37 | 52 | 89 |
| 2021 September | 27 | 35 | 62 |
| 2021 August | 27 | 50 | 77 |
| 2021 July | 24 | 27 | 51 |
| 2021 June | 33 | 38 | 71 |
| 2021 May | 39 | 44 | 83 |
| 2021 April | 105 | 109 | 214 |
| 2021 March | 56 | 26 | 82 |
| 2021 February | 24 | 25 | 49 |
| 2021 January | 21 | 21 | 42 |
| 2020 December | 38 | 29 | 67 |
| 2020 November | 23 | 17 | 40 |
| 2020 October | 18 | 14 | 32 |
| 2020 September | 21 | 19 | 40 |
| 2020 August | 28 | 19 | 47 |
| 2020 July | 22 | 28 | 50 |
| 2020 June | 16 | 14 | 30 |
| 2020 May | 12 | 12 | 24 |
| 2020 April | 34 | 17 | 51 |
| 2020 March | 18 | 9 | 27 |
| 2020 February | 20 | 22 | 42 |
| 2020 January | 23 | 12 | 35 |
| 2019 December | 32 | 23 | 55 |
| 2019 November | 18 | 21 | 39 |
| 2019 October | 25 | 17 | 42 |
| 2019 September | 11 | 9 | 20 |
| 2019 August | 16 | 13 | 29 |
| 2019 July | 18 | 15 | 33 |
| 2019 June | 8 | 4 | 12 |
| 2019 May | 12 | 21 | 33 |
| 2019 April | 23 | 41 | 64 |
| 2019 March | 22 | 16 | 38 |
| 2019 February | 16 | 9 | 25 |
| 2019 January | 20 | 18 | 38 |
| 2018 December | 22 | 12 | 34 |
| 2018 November | 79 | 20 | 99 |
| 2018 October | 125 | 26 | 151 |
| 2018 September | 31 | 12 | 43 |
| 2018 May | 19 | 0 | 19 |
| 2018 April | 33 | 9 | 42 |
| 2018 March | 31 | 9 | 40 |
| 2018 February | 29 | 5 | 34 |
| 2018 January | 97 | 13 | 110 |
| 2017 December | 120 | 14 | 134 |
| 2017 November | 25 | 9 | 34 |
| 2017 October | 30 | 7 | 37 |
| 2017 September | 28 | 21 | 49 |
| 2017 August | 0 | 1 | 1 |
| 2017 June | 0 | 1 | 1 |
| 2017 May | 0 | 2 | 2 |
Show all
