In late 2025, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 report for chronic obstructive pulmonary disease (COPD) was released. Frank C. Sciurba, MD, FCCP, comments on the updates on pharmacologic maintenance treatment—and their implications for clinical practice—as discussed at the recent American Thoracic Society International Conference 2026 (ATS 2026).

Following this presentation, featured expert Frank C. Sciurba, MD, FCCP, was interviewed by Conference Reporter Medical Director Lauren Weinand, MD. Clinical perspectives from Dr Sciurba on these findings are presented here.

At ATS 2026, Antonio R. Anzueto, MD, ATSF, spoke on the GOLD 2026 report for COPD. I have a strong respect for Dr Anzueto and for the work of the GOLD Science Committee, although my own interpretations of the report may differ in clinical practice.

During his presentation, Dr Anzueto summarized the GOLD recommendations for initiation and follow-up therapy. There are 2 broad domains of COPD that should be considered when selecting therapy: symptoms, including dyspnea resulting in exertional intolerance (which is often associated with cough and sputum), and exacerbation frequency. Often, the initiation of and subsequent adjustment to therapy will be guided by these aspects of a patient’s presentation. Another factor that is increasingly included in decision making at both initiation and follow-up is the blood eosinophil level.

The GOLD 2026 report recommends that the fundamental treatment for all symptomatic patients with COPD—whether or not they have exacerbations—should be dual therapy with a LAMA and LABA. Previous guidelines recommended only single-agent treatment with either a LAMA or LABA, and there continues to be a small role for these single agents in a subset of patients who are relatively asymptomatic and only have exertional symptoms. However, we now know that almost all patients with COPD should, at a minimum, be prescribed the combination, particularly if they have symptoms and especially if they have exacerbations.

The next treatment decision is determining which patients should get ICS therapy. We know that these agents do have a downside: the chronic use of an ICS agent is associated with an increased risk of pneumonia in some patients with COPD. While most pulmonologists would agree that the upside of ICS treatment is very important, we also need to consider the potential risks. So, if we have reason to believe that ICS therapy will confer no benefit for the patient, then we should limit treatment to LAMA-LABA combination therapy.

A consideration that might push me toward adding ICS therapy is the occurrence of frequent exacerbations. In the updated GOLD report, frequent exacerbations are now defined as just 1 exacerbation per year. This is where I think there is some texture involved in interpreting the GOLD recommendations. Patients with exacerbations and eosinophil counts of 300 cells/µL or higher should likely be initiated on triple therapy with ICS treatment. But do you treat a patient with 1 exacerbation differently than you would treat a patient with 2 or 3 exacerbations? Do you differentiate treatment for a patient whose eosinophil levels are 290 cells/µL vs one whose levels are 120 cells/µL?

According to the GOLD report, if a patient has fewer than 100 eosinophils, they are unlikely to respond to ICS treatment. If a patient’s eosinophil count is 300 cells/µL or higher, there is a very good chance that they will respond to ICS therapy. If they fall between approximately 100 and 300 cells/µL, ICS can be considered; however, the response to ICS treatment is diminished compared with that of patients with eosinophil counts of higher than 300 cells/µL. This is a patient population for whom you need to factor in multiple considerations. Are they failing dual therapy and having frequent exacerbations? At that point, I would have a low threshold for adding ICS therapy. However, what do you do for patients who have fewer than 100 eosinophils, are on LAMA-LABA therapy, and continue to exacerbate? For this subgroup, the GOLD report recommends considering additional maintenance treatment with roflumilast or azithromycin.

Looking forward, there are some exciting new therapies coming down the pike, particularly the IL-33 monoclonal antibodies. These agents may offer an additional maintenance treatment option to patients with COPD who have low eosinophil counts and continue to exacerbate. We now also have dupilumab and mepolizumab as additional maintenance treatment options for patients on triple therapy with high eosinophil counts who continue to exacerbate.

One controversial point of discussion that was not included in the GOLD 2026 report is the role of ensifentrine, a PDE3 and PDE4 inhibitor. Ensifentrine has been shown to decrease exacerbations, but the clinical trials did not include patients on dual therapy. Patients in the study were being treated with only 1 bronchodilator. Although the evidence is a little sparse, in clinical practice, I find that many pulmonologists are adding ensifentrine for patients with ongoing exacerbations and low Th2-type signals. We need ongoing clinical trials to give us the evidence base to support this strategy.

Overall, in real-world clinical practice, treatment is not well standardized. If you look at hospital admissions and discharges, probably less than 50% of patients are receiving what is considered appropriate guideline-based therapy (ie, LAMA-LABA therapy with or without ICS therapy). So, before we consider more advanced therapies, let us first apply the basics: the treatments that we already know work in these patients.