Table 1.

Therapy at each grade of chronic obstructive pulmonary disease as recommended by GOLD (Global Initiative for Chronic Obstructive Lung Disease)

Patient group	First choice	Second choice	Alternative choiceb
Initial pharmacologic management of COPDa
A	Short-acting anticholinergic prn or short-acting beta2-agonist prn	Long-acting anticholinergic or long-acting beta2-agonist or short-acting beta2-agonist and short-acting anticholinergic	Theophylline
B	Long-acting anticholinergic or long-acting beta2-agonist	Long-acting anticholinergic and long-acting beta2-agonist	Short-acting beta2-agonist and/or short-acting anticholinergic Theophylline
C	Inhaled corticosteroid + long-acting beta2-agonist or long-acting anticholinergic	Long-acting anticholinergic and long-acting beta2-agonist	Phosphodiesterase-4 inhibitor Short-acting beta2-agonist and/or short-acting anticholinergic Theophylline
D	Inhaled corticosteroid + long-acting beta2-agonist or long-acting anticholinergic	Inhaled corticosteroid and long-acting anticholinergic or inhaled corticosteroid + long-acting beta2-agonist and long-acting anticholinergic or inhaled corticosteroid + long-acting beta2-agonist and phosphodiesterase-4 inhibitor or long-acting anticholinergic and long-acting beta2-agonist or long-acting anticholinergic and phosphodiesterase-4 inhibitor	Carbocysteine Short-acting beta2-agonist and/or short-acting anticholinergic Theophylline

Notes: Group A: few symptoms and low risk of exacerbations. GOLD 1 or 2 (mild/moderate airflow limitation) and/or 0–1 exacerbation per year and mMRC grade 0–1 or CAT score < 10. Group B: more significant symptoms; low risk of exacerbations. GOLD 1 or 2 (mild/moderate airflow limitation) and/or 0–1 exacerbation per year and mMRC grade ≥ 2 or CAT score ≥ 10. Group C: few symptoms; high risk of exacerbations. GOLD 3 or 4 (severe/very severe airflow limitation) and/or ≥2 exacerbations per year and mMRC grade 0–1 or CAT score < 10. Group D: many symptoms; high risk of exacerbations. GOLD 3 or 4 (severe/very severe airflow limitation) and/or ≥2 exacerbations per year and mMRC grade ≥ 2 or CAT score ≥ 10.

^aMedications in each box are mentioned in alphabetical order, and therefore not necessarily in order of preference;

^bmedications in this column can be used alone or in combination with other options in the first and second columns.

^aCopyright © 2011, Global Initiative for Chronic Obstructive Lung Disease. Reproduced with permission from Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease. Updated Dec 2011. Available from: http://www.goldcopd.org. Accessed July 5, 2012.⁴

Abbreviations: CAT, COPD Assessment Test; COPD, chronic obstructive pulmonary disease; mMRC, Modified British Medical Research Council; prn, taken as needed.