Lung Function and the GOLD ABE Classification: Do We Need to “Go Back to the Future”?

To the Editor,

The 2026 GOLD report introduces a new algorithm for initiating pharmacologic treatment in patients with chronic obstructive pulmonary disease (COPD).¹ According to this updated approach, patients who experience a single moderate or severe exacerbation in the previous year are classified as group E. Consequently, the recommended treatment for these patients should be either long-acting beta-agonists (LABA) combined with long-acting muscarinic agents (LAMA), or LABA + LAMA + inhaled corticosteroids, depending on their blood eosinophil count. A recent manuscript by Dr. Miravitlles reviews the implications of this new algorithm, highlighting concerns about the potential for overtreatment.² We consider this paper to be an insightful and clarifying reflection. We agree that additional factors should be taken into account to guide treatment decisions aimed at reducing future risk in these patients.²

While personalized treatment at the individual level is desirable in any disease, standardizing pharmacological approaches within clinical guidelines offers clear advantages – such as improving consistency in therapy, balancing benefits and risks, and controlling healthcare costs – particularly in a complex disease like COPD, which involves multiple specialties and levels of care.

Among the factors that Dr. Miravitlles accurately suggests for guiding initial therapy in patients with few previous moderate exacerbations – such as age, disease severity, comorbidities, and patient preferences – one stands out for its simplicity and practicality: the level of ventilatory obstruction. Although this variable was initially incorporated into the GesEPOC classification of future risk based on expert opinion rather than robust evidence, subsequent studies have demonstrated that the severity of FEV₁ impairment – using a cutoff of 50% of predicted – can predict adverse clinical outcomes, including severe exacerbations and mortality.^3,4

This evidence supports the use of the GesEPOC risk classification – and lung function parameters specifically – as valuable tools in decision-making when initiating pharmacological therapy in COPD. Our own research has shown that reclassifying patients previously categorized as group A in the old GOLD ABCD system into A1 or A2-based on whether their FEV₁ is above or below 50% of predicted- can distinguish differences in the risk of all-cause mortality (hazard ratio 1.77; 95% CI: 1.06–2.98; p = 0.02 for A2 vs. A1) and future severe exacerbations (HR 1.76; 95% CI: 1.14–2.71; p = 0.01). These differences remained significant both in unadjusted models and after adjusting for the age-adjusted Charlson comorbidity index.⁵

Consequently, it is reasonable to hypothesize that patients previously classified as group A who meet both the criterion of a single moderate exacerbation and have a FEV₁ below 50%, may be the best candidates to be reclassified as GOLD E. This reclassification could strike a balance between reducing future risk and avoiding overtreatment.

In light of this, it is worth considering whether looking back to previous GOLD schemes – those that incorporated lung function into therapeutic algorithms – can inform and enhance the future management of COPD.

AI involvement

Artificial intelligence tools were used exclusively to support language editing. All the manuscript's content was generated, reviewed and validated by the authors.

Informed consent

This manuscript does not present new patient data; therefore, ethical considerations do not apply. We reference a previously published study approved by the Clinical Research Ethics Committee of the Hospital Universitario Nuestra Señora de Candelaria (Registry number: CHUNSC_2021_08). Informed consent was waived for that study by the Ethics Committee due to its retrospective design and the anonymous collection of data.

Funding

This manuscript received no funding.

Authors’ contributions

Both authors contributed equally to the drafting of the manuscript.

Conflicts of interest

RG has received speaking or advisory fees, or economic aid to attend congresses from AstraZeneca, GSK, Novartis, FAES, Chiesi, Mundipharma, Menarini, TEVA, Grifols, Ferrer, Boehringer Ingelheim, Rovi, and Gebro; JMFG has received honoraria for speaking engagements and funding for conference attendance from Laboratories Esteve, MundiPharma, AstraZeneca, Boehringer Ingelheim, Ferrer, Menarini, Rovi, GSK, Chiesi, Novartis, and Gebro Pharma.