Editorial
Differences Between GesEPOC and GOLD in 2017
Diferencias entre GesEPOC y GOLD en el año 2017
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Marin" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Juan P." "apellidos" => "de-Torres" "email" => array:1 [ 0 => "jpdetorres@unav.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Jose M." "apellidos" => "Marin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Neumología, Clínica Universidad de Navarra, Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neumología, Hospital Universitario Miguel Servet, Zaragoza, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Diferencias entre GesEPOC y GOLD en el año 2017" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The GesEPOC Spanish COPD guidelines first appeared in 2012,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> and were subsequently updated in 2014. For the first time in the international medical literature, a different approach was proposed for the classification of clinical phenotypes and corresponding treatment strategies. This clinical practice guideline stratified disease severity from a multidimensional standpoint, taking into account symptom intensity, risk of exacerbations, lung function involvement, and the use of multidimensional indices such as BODE or BODEx.</p><p id="par0010" class="elsevierStylePara elsevierViewall">One year earlier, in 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) published an update containing new recommendations.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> In this update, the approach to the disease changed substantially, switching from disease management focused uniquely on FEV1, to a multidimensional strategy based on bronchial obstruction, symptoms, and risk of exacerbations. This reflected an acceptance of the new mindset proposed by the BODE group, which aimed to reverse the old nihilism surrounding COPD: patients are more than just subjects with gradually deteriorating, irreversible FEV1. Other factors such as dyspnea, exercise capacity, and nutritional status determine prognosis and can be modified with treatment.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3,4</span></a> This year, 2017, has seen the publication of new updates of both GesEPOC and GOLD, both of which adopt a multidimensional perspective to some extent or other. Our aim in this short editorial is to discuss the differences in these guidelines, as summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">GesEPOC is a clinical practice guideline sponsored by scientific societies (primarily SEPAR), while GOLD is the work of a team of independent experts. The two documents are distinct types: GesEPOC is a clinical practice guideline that combines recommendations based on Grade of Recommendations Assessment, Development and Evaluation (GRADE) methodology with the opinion of experts in aspects where the GRADE methodology is not applicable; GOLD is a strategic document based on expert opinion after a systematic literature review.</p><p id="par0020" class="elsevierStylePara elsevierViewall">There are no essential differences in the concept of diagnosis, except with regard to the cutoff points for recommending spirometry in former and active smokers: 10 pack-years in GesEPOC and 20 pack-years in GOLD.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Both proposals embrace a similar concept of COPD as a multidimensional disease, but post-diagnosis therapeutic approaches diverge. GesEPOC uses three dimensions to determine risk: lung function, symptoms, and exacerbations in the previous year. The concept of risk refers to the probability of future exacerbations, disease progression, complications, use of health resources, and death. Risk is categorized as low or high. GOLD now uses the conventional definition of grades of obstruction for prognostic purposes only, and includes only a two-dimensional assessment (symptoms and history of exacerbations) to guide treatment. Both documents use similar cutoff points for exacerbations, but GesEPOC bases its classification on MRC scale symptoms, while GOLD still uses the COPD Assessment Test (CAT).</p><p id="par0030" class="elsevierStylePara elsevierViewall">In the updated GesEPOC, clinical phenotype is now determined in high-risk patients only.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> This simplifies patient evaluation: treatment of low-risk patients is based on bronchodilation, while a more personalized intervention is recommended in high-risk patients. The new update of the GOLD recommendations<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> has removed the term “inflammation” from its definition, thus reducing the importance of inhaled corticosteroids (ICS), and placing more emphasis on bronchodilators. The conventional classification of severity grades is maintained only for prognostic purposes, but not for guiding treatment.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The main difference between these documents still lies in use of drugs, which paradoxically is based on the same evidence. GesEPOC has simplified treatment by stratifying risk. The therapeutic scheme places more importance on LAMAs and dual bronchodilation in low-risk patients. In high-risk patients more importance is given to dual bronchodilation, with ICS as first-choice therapy only in the asthma-COPD overlap syndrome (ACOS) phenotype, and as a second-choice after bronchodilation in frequent exacerbators. The GOLD therapeutic recommendations are two-dimensional, focusing on symptoms and previous history of exacerbations. Bronchodilators form the therapeutic backbone, with the possible use of either LAMA or LABA, but more probably a combination of the two, while ICS are reserved for group C or D exacerbators, and always in combination with LABA or LAMA.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Despite the difficulties in reaching a robust definition of the ACOS phenotype, this concept is recognized in GesEPOC and treatment recommendations are given, while in GOLD it is only mentioned.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, it seems that, echoing the old slogan “Spain is different”, the GesEPOC approach, while based on the same evidence, is new and different. Although robust evidence is needed to support this new version of the guidelines, there is little doubt that that it is fresh and innovative, and will generate constructive discussions on the different fora.</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: de Torres JP, Marin JM. Diferencias entre GesEPOC y GOLD en el año 2017. Arch Bronconeumol. 2017;53:295–296.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>: ACOS: asthma-COPD overlap syndrome; CAT: COPD Assessment Test scale; FEV1: forced expiratory volume in 1 second on post-bronchodilator spirometry; ICS: inhaled corticosteroids; LABA: long-acting beta-adrenergic bronchodilator; LAMA: long-acting antimuscarinic bronchodilator; MRC: Medical Research Council dyspnea scale.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristics \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GesEPOC 2017 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">GOLD 2017 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sponsor \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Scientific societies \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Private initiative \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Definition \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Persistent symptoms and chronic airflow limitation, caused mainly by smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Persistent symptoms and airflow limitation caused by significant exposure to toxic particles or fumes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spirometry \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History of >10 pack-years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">History of >20 pack-years \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Risk stratification \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Post-bronchodilator FEV1<br>Symptoms (dyspnea according to MRC)<br>Exacerbations previous year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Symptoms (MRC or CAT)<br>Exacerbations previous year<br>(Groups A, B, C, and D) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">High risk \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">FEV1 <50% predicted or<br>MRC >2, or<br>≥2 exacerbations or 1 hospitalization in previous year \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">≥2 exacerbations or 1 hospitalization in previous year (C and D) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Phenotypes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">For high-risk patients \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No phenotypes \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Initial pharmacological treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Low risk: LAMA<br>High risk: LABA-LABA (If ACOS: LABA-ICS) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Group A: “a bronchodilator”<br>Group B: LABA or LAMA<br>Group C: LAMA<br>Group D: LAMA + LABA or<br>LAMA+ICS \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1459537.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Differences between GesEPOC and GOLD in 2017.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spanish COPD Guidelines (GesEPOC): Pharmacological treatment of stable COPD. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 3 | 8 |
| 2024 October | 41 | 21 | 62 |
| 2024 September | 46 | 18 | 64 |
| 2024 August | 65 | 31 | 96 |
| 2024 July | 35 | 22 | 57 |
| 2024 June | 73 | 28 | 101 |
| 2024 May | 75 | 31 | 106 |
| 2024 April | 40 | 28 | 68 |
| 2024 March | 48 | 14 | 62 |
| 2024 February | 34 | 29 | 63 |
| 2023 March | 3 | 6 | 9 |
| 2023 February | 29 | 20 | 49 |
| 2023 January | 22 | 42 | 64 |
| 2022 December | 44 | 36 | 80 |
| 2022 November | 52 | 31 | 83 |
| 2022 October | 40 | 36 | 76 |
| 2022 September | 43 | 40 | 83 |
| 2022 August | 61 | 49 | 110 |
| 2022 July | 59 | 47 | 106 |
| 2022 June | 29 | 34 | 63 |
| 2022 May | 29 | 34 | 63 |
| 2022 April | 28 | 39 | 67 |
| 2022 March | 39 | 42 | 81 |
| 2022 February | 22 | 34 | 56 |
| 2022 January | 28 | 42 | 70 |
| 2021 December | 29 | 46 | 75 |
| 2021 November | 35 | 38 | 73 |
| 2021 October | 38 | 49 | 87 |
| 2021 September | 26 | 40 | 66 |
| 2021 August | 28 | 56 | 84 |
| 2021 July | 29 | 28 | 57 |
| 2021 June | 31 | 44 | 75 |
| 2021 May | 39 | 41 | 80 |
| 2021 April | 66 | 78 | 144 |
| 2021 March | 45 | 30 | 75 |
| 2021 February | 35 | 31 | 66 |
| 2021 January | 33 | 26 | 59 |
| 2020 December | 34 | 26 | 60 |
| 2020 November | 27 | 25 | 52 |
| 2020 October | 17 | 19 | 36 |
| 2020 September | 19 | 17 | 36 |
| 2020 August | 29 | 15 | 44 |
| 2020 July | 15 | 33 | 48 |
| 2020 June | 19 | 12 | 31 |
| 2020 May | 18 | 8 | 26 |
| 2020 April | 22 | 16 | 38 |
| 2020 March | 12 | 12 | 24 |
| 2020 February | 24 | 20 | 44 |
| 2020 January | 31 | 21 | 52 |
| 2019 December | 30 | 17 | 47 |
| 2019 November | 24 | 26 | 50 |
| 2019 October | 20 | 8 | 28 |
| 2019 September | 12 | 10 | 22 |
| 2019 August | 16 | 13 | 29 |
| 2019 July | 20 | 16 | 36 |
| 2019 June | 12 | 4 | 16 |
| 2019 May | 25 | 14 | 39 |
| 2019 April | 29 | 28 | 57 |
| 2019 March | 28 | 26 | 54 |
| 2019 February | 30 | 11 | 41 |
| 2019 January | 27 | 20 | 47 |
| 2018 December | 35 | 21 | 56 |
| 2018 November | 55 | 23 | 78 |
| 2018 October | 223 | 22 | 245 |
| 2018 September | 24 | 13 | 37 |
| 2018 May | 51 | 0 | 51 |
| 2018 April | 30 | 11 | 41 |
| 2018 March | 91 | 4 | 95 |
| 2018 February | 41 | 12 | 53 |
| 2018 January | 38 | 13 | 51 |
| 2017 December | 44 | 16 | 60 |
| 2017 November | 31 | 28 | 59 |
| 2017 October | 27 | 28 | 55 |
| 2017 September | 48 | 15 | 63 |
| 2017 August | 1 | 2 | 3 |
| 2017 June | 4 | 1 | 5 |
| 2017 May | 1 | 7 | 8 |
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