Hello, and thank you for joining. In the next two minutes, we'll focus on the key GOLD 2026 highlights related to bronchodilator use in COPD.

GOLD recommendations support the use of LAMA and LABA dual bronchodilation as the preferred way to initiate treatment for patients in both Group B and Group E. Note that in the 2026 GOLD Recommendations, Group B patients are defined as those who had no moderate or severe exacerbations in the previous year and have an mMRC ≥2 and CAAT ≥10.

Group E patients are defined as those who had one or more moderate or severe exacerbations in the previous year.

In 2023, there was a shift in COPD initial treatment to recommend dual long-acting bronchodilation rather than starting with a single long-acting bronchodilator in Group B patients.

GOLD 2026 recommends LAMA/LABA dual bronchodilation as an initial treatment option for appropriate patients in Group B and Group E based on symptom burden and exacerbation risk.

For patients already on bronchodilator monotherapy who remain dyspneic, GOLD recommendations support stepping up to dual bronchodilation.

At the same time, a LABA plus inhaled corticosteroid (ICS) has a more limited role in COPD, and if an ICS is indicated, GOLD recommends triple therapy (LAMA + LABA + ICS) instead of a LABA plus ICS alone.

For group A, treatment still begins with a bronchodilator, chosen based on its effect on breathlessness and continued if benefit is documented. Patients in Group A are defined as those who had no moderate or severe exacerbations in the previous year and have an mMRC of 0 to 1 and CAAT less than 10.

For group B, GOLD recommends starting with LAMA and LABA dual bronchodilation, reflecting changes introduced in the GOLD 2023 initial treatment recommendations.

For group E the recommended initial option is also LAMA and LABA when blood eosinophil counts are less than 300 cells/microliter.

If eosinophil counts are greater than or equal to 300 cells/microliter, triple therapy with LABA, LAMA, and ICS may be considered. Decisions regarding ICS use should take into account exacerbation risk and blood eosinophil count.

Follow-up care is built around a review, assess, and adjust cycle.

When dyspnea persists, start by reassessing the cause. Symptoms may reflect comorbidity, deconditioning, poor inhaler adherence, or another explanation beyond airflow limitation alone.

It's also important to check inhaler technique and confirm that the device matches the patient's abilities, such as inspiratory flow, coordination, and consistent use.

In follow-up treatment, persistent dyspnea generally points toward optimizing bronchodilation, while recurrent exacerbations may prompt consideration of ICS containing triple therapy, depending on blood eosinophil counts.

So, GOLD recommends LAMA/LABA dual bronchodilation as initial pharmacologic treatment for Groups B and E, with ICS-containing triple therapy considered for select patients based on exacerbation risk and blood eosinophil count.

Thank you for your time in this important matter. I hope you found this discussion helpful.

The 2026 GOLD Report reinforces and clarifies the central role of LAMA/LABA combination therapy¹

• Group B (high symptom burden, mMRC ≥2 or CAAT ≥10, without significant exacerbation history): LAMA/LABA is the recommended initial therapy, rather than a choice between monotherapy and dual therapy reflecting changes introduced in the GOLD 2023 initial treatment recommendations.

• Group E (≥1 moderate or severe exacerbation in the past year): Group E now includes patients with even a single moderate/severe exacerbation, reflecting evidence that one exacerbation increases the risk of future events. For these patients, LAMA/LABA is the recommended initial therapy. ICS-containing triple therapy may be considered initially if blood eosinophils are ≥300 cells/μL.

• Since the landmark changes in 2023, LABA/ICS is no longer encouraged: GOLD 2026 explicitly states that LABA/ ICS combination therapy is no longer encouraged for COPD. If ICS is indicated, it should be added to a LAMA/ LABA foundation (i.e., triple therapy), not paired with LABA alone.

The clinical significance of a single exacerbation

Exacerbations of COPD are important events that negatively impact health status, contribute to disease progression, and enhance the rate of lung function decline.¹

Research has shown that experiencing even one moderate or severe COPD exacerbation increases the risk of subsequent exacerbations approximately 4-fold.²

GOLD's 2026 redefinition of Group E (lowering the threshold from ≥2 to ≥1 moderate/severe exacerbation) reflects this evidence.^1,3

Maximizing bronchodilation through two mechanisms^1,3

LAMA and LABA agents produce bronchodilation through independent pathways:

• LAMAs inhibit M3 muscarinic receptors on airway smooth muscle, blocking cholinergic bronchoconstriction

• LABAs activate beta2-adrenoceptors, stimulating intracellular adenyl cyclase to elevate cyclic AMP, which relaxes airway smooth muscle

According to GOLD 2026, combining bronchodilators with different mechanisms and duration of action may increase the degree of bronchodilation compared to increasing the dose of a single bronchodilator.¹

GOLD 2026 supports LAMA/LABA dual therapy over either component alone for patients with higher symptom burden (Group B) or exacerbation history (Group E).¹

GOLD 2026 includes recommendations regarding inhaler device selection and use in patients with COPD¹

GOLD 2026 emphasizes that appropriate device selection requires consideration of multiple patient-specific factors. Poor inhaler technique is common among patients with COPD.

GOLD 2026 also recognizes that simplifying a patient's regimen, for example by using a single inhaler, may support adherence. Where clinically appropriate, this may help reduce treatment complexity and support consistent use.

Current guidelines support patient education on inhaler use¹

GOLD 2026 recommends that inhaler technique be regularly assessed and reinforced during patient interactions.