Abstract
Precision medicine is a patient specific approach that integrates all relevant clinical, genetic and biological information in order to optimise the therapeutic benefit relative to the possibility of side effects for each individual. Recent clinical trials have shown that higher blood eosinophil counts are associated with a greater efficacy of inhaled corticosteroids (ICS) in COPD patients. Blood eosinophil counts are a biomarker with potential to be used in clinical practice, to help target ICS treatment with more precision in COPD patients with a history of exacerbations despite appropriate bronchodilator treatment.
The Global initiative for the management of chronic Obstructive Lung Disease (GOLD) 2017 pharmacological treatment algorithms, based on the ABCD assessment, can be applied relatively easily to treatment naïve individuals at initial presentation. However, their use is more problematic during follow up in patients who are already on maintenance treatment. There is a need for a different system to guide COPD pharmacological management during follow up.
Recent large randomised controlled trials have provided important new information concerning the therapeutic effects of ICS and long-acting bronchodilators on exacerbations. The new evidence regarding blood eosinophils and inhaled treatments, and the need to distinguish between initial and follow up pharmacological management, led to changes in the GOLD pharmacological treatment recommendations. This paper explains the evidence and rationale for the GOLD 2019 pharmacological treatment recommendations.
Footnotes
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Conflict of interest: Dr. Singh reports grants and personal fees from GlaxoSmithKline, grants and personal fees from AstraZeneca, grants and personal fees from Boehringer Ingleheim, grants and personal fees from Chiesi, personal fees from Cipla, personal fees from Genentech, grants and personal fees from Glenmark, grants and personal fees from Menarini, grants and personal fees from Mundipharma, grants and personal fees from Novartis, personal fees from Peptinnovate, grants and personal fees from Pfizer, grants and personal fees from Pulmatrix, grants and personal fees from Therevance, grants and personal fees from Verona, outside the submitted work.
Conflict of interest: Dr. Agusti reports personal fees from AstraZeneca, grants and personal fees from Menarini, personal fees from Chiesi, grants and personal fees from GSK, personal fees from Nuvaira, outside the submitted work.
Conflict of interest: Dr. Anzueto reports personal fees from AstraZeneca, grants and personal fees from GlaxoSmithKline, personal fees from Novartis, personal fees from Boehringer-Ingelheim, personal fees from Sunovion Pharmaceutical, outside the submitted work.
Conflict of interest: Dr. Barnes reports grants and personal fees from AstraZeneca, grants and personal fees from Boehringer Ingelheim, personal fees from Pieris, personal fees from Novartis, personal fees from Teva, outside the submitted work.
Conflict of interest: Dr. Bourbeau reports grants from CIHR, grants from Canadian Respiratory Research Network (CRRN), personal fees from Canadian Thoracic Society, personal fees from CHEST, grants from Foundation of the MUHC, grants from Aerocrine, grants and personal fees from AstraZeneca, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Grifols, grants and personal fees from GlaxoSmithKline, grants and personal fees from Novartis, grants and personal fees from Trudell, outside the submitted work.
Conflict of interest: Dr. Celli reports personal fees and other from Astra Zeneca, personal fees from GlaxoSmithKline, personal fees from Boehringer Ingelheim, personal fees from Novartis, personal fees from Sanofi Aventis and personal fess form Menarini other from outside the submitted work.
Conflict of interest: Dr. Criner reports grants and personal fees from Galaxo Smith Kline, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Chiesi, grants and personal fees from Mereo, personal fees from Verona, grants and personal fees from Astra Zeneca, grants and personal fees from Pulmonx, grants and personal fees from Pneumrx, personal fees from BTG, grants and personal fees from Olympus, grants and personal fees from Broncus, personal fees from EOLO, personal fees from NGM, grants and personal fees from Lungpacer, grants from Alung, grants and personal fees from Nuvaira, grants and personal fees from ResMed, grants and personal fees from Respironics, grants from Fisher Paykel, grants and personal fees from Patara, grants from Galapgos, outside the submitted work.
Conflict of interest: Dr. Frith reports non-financial support from Global Initiative for Chronic Obstructive Lung Disease (GOLD), during the conduct of the study; personal fees from AstraZeneca, personal fees and non-financial support from Boehringer Ingelheim, non-financial support from GlaxoSmithKline, personal fees and non-financial support from Novartis, non-financial support from Lung Foundation Australia (LFA), personal fees and non-financial support from CSL-Behring, outside the submitted work.
Conflict of interest: Dr. Halpin reports personal fees from AstraZeneca, personal fees and non-financial support from Boehringer Ingelheim, personal fees from Chiesi, personal fees from GlaxoSmithKline, personal fees and non-financial support from Novartis, personal fees from Pfizer, outside the submitted work.
Conflict of interest: Dr. Han reports personal fees from GSK, personal fees from BI, personal fees from AstraZeneca, other from Novartis, other from Sunovion, outside the submitted work.
Conflict of interest: Dr. Lopez Varela has nothing to disclose.
Conflict of interest: Dr. Martinez reports personal fees, non-financial support and other from Boehringer Ingelheim, during the conduct of the study; personal fees and non-financial support from American College of Chest Physicians, personal fees and non-financial support from AstraZeneca, personal fees and non-financial support from Boehringer Ingelheim, non-financial support from ProterrixBio, personal fees and non-financial support from Continuing Education, personal fees from Columbia University, personal fees and non-financial support from ConCert, personal fees and non-financial support from Genentech, personal fees and non-financial support from GlaxoSmithKline, personal fees and non-financial support from Inova Fairfax Health System, personal fees from Integritas, personal fees from MD Magazine, personal fees from Methodist Hospital Brooklyn, personal fees and non-financial support from Miller Communicatinos, personal fees and non-financial support from National Association for Continuing Education, personal fees and non-financial support from Novartis, personal fees from New York University, personal fees and non-financial support from Pearl Pharmaceuticals, personal fees and non-financial support from PeerView Communications, personal fees and non-financial support from Prime Communications, personal fees and non-financial support from Puerto Rican Respiratory Society, personal fees and non-financial support from Chiesi, personal fees and non-financial support from Roche, personal fees and non-financial support from Sunovion, personal fees and non-financial support from Theravance, personal fees from Unity, personal fees from UpToDate, personal fees from WebMD/MedScape, personal fees from Western Connecticut Health Network, other from Afferent/Merck, personal fees from Academic CME, non-financial support from Gilead, non-financial support from Nitto, personal fees from Patara, personal fees from PlatformIQ, personal fees and non-financial support from Potomac, other from Biogen, personal fees and non-financial support from University of Alabama Birmingham, other from Veracyte, non-financial support from Zambon, personal fees from American Thoracic Society, grants from NIH, personal fees and non-financial support from Physicians Education Resource, personal fees from Rockpointe, other from Prometic, grants from Rare Disease Healthcare Communications, other from Bayer, other from Bridge Biotherapeutics, personal fees and non-financial support from Canadian Respiratory Network, grants from ProMedior, personal fees and non-financial support from Teva, outside the submitted work.
Conflict of interest: Dr. Montes de Oca has nothing to disclose.
Conflict of interest: Dr. Papi reports grants, personal fees, non-financial support and other from Chiesi, grants, personal fees, non-financial support and other from Astrazeneca, grants, personal fees, non-financial support and other from GlaxoSmithKline, grants, personal fees, non-financial support and other from Boehringer Ingelheim, grants, personal fees and non-financial support from Menarini, personal fees and non-financial support from Novartis, personal fees and non-financial support from Zambon, grants, personal fees, non-financial support and other from Mundipharma, grants, personal fees, non-financial support and other from TEVA, personal fees and non-financial support from Sanofi, outside the submitted work.
Conflict of interest: Dr. Pavord reports personal fees from AstraZeneca, personal fees from GSK, personal fees from Boehringer Ingelheim, grants and personal fees from Chiesi, personal fees from Sanofi/Regeneron, personal fees from Circassia, personal fees from Merck, personal fees from Novartis, personal fees from Mundipharma, personal fees from Teva, personal fees from Knopp, grants and personal fees from Afferent, personal fees from Roche/Genentech, outside the submitted work.
Conflict of interest: Dr. Roche reports grants and personal fees from Boehringer Ingelheim, grants and personal fees from Novartis, personal fees from Teva, personal fees from GSK, personal fees from AstraZeneca, personal fees from Chiesi, personal fees from Mundipharma, grants and personal fees from Pfizer, personal fees from Sanofi, personal fees from Sandoz, personal fees from 3M, personal fees from Zambon, outside the submitted work.
Conflict of interest: Dr. Sin reports grants from AstraZeneca, during the conduct of the study; grants from Merck, personal fees from Sanofi-Aventis, personal fees from Regeneron, grants and personal fees from Boehringer Ingelheim, grants and personal fees from AstraZeneca, personal fees from Novartis, outside the submitted work.
Conflict of interest: Dr. Stockley reports personal fees from AstraZeneca, personal fees from MedImmune, personal fees from Almirall, personal fees from Nycomed, personal fees from Takeda, personal fees from Boehringer Ingelheim, grants and personal fees from CSL Behring, personal fees from Kamada, personal fees from Baxter, personal fees from Chiesi, personal fees from Polyphor, personal fees from GlaxoSmithKline, outside the submitted work.
Conflict of interest: Dr. Vestbo reports personal fees from GlaxoSmithKline, personal fees from Chiesi Pharmaceuticals, personal fees from Boehringer-Ingelheim, personal fees from Novartis, personal fees from AstraZeneca, grants from Boehringer-Ingelheim, outside the submitted work.
Conflict of interest: Dr. Wedzicha reports grants from GSK, grants from Johnson and Johnson, other from Novartis, other from Boehringer Ingelheim, other from Astra Zeneca, other from GSK, grants from GSK, grants from Astra Zeneca, grants from Boehringer Ingelheim, grants from Novartis, grants from Chiesi, outside the submitted work.
Conflict of interest: Dr. Vogelmeier reports personal fees from Almirall, grants and personal fees from AstraZeneca, grants and personal fees from Boehringer Ingelheim, grants and personal fees from Chiesi, grants and personal fees from GlaxoSmithKline, grants and personal fees from Grifols, grants and personal fees from Mundipharma, grants and personal fees from Novartis, grants and personal fees from Takeda, personal fees from Cipla, personal fees from Berlin Chemie/Menarini, personal fees from CSL Behring, personal fees from Teva, grants from German Federal Ministry of Education and Research (BMBF) Competence Network Asthma and COPD (ASCONET), grants from Bayer Schering Pharma AG, grants from MSD, grants from Pfizer, outside the submitted work.
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