A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 45% predicted) has 3 exacerbations in the previous year including one requiring hospitalisation. He is on LAMA + LABA. Blood eosinophil count is 450 cells/μL. Which additional therapy is most appropriate per GOLD 2024 guidelines?

• A Add roflumilast (PDE-4 inhibitor) to LAMA + LABA
• B Add inhaled corticosteroid (ICS) to form LAMA + LABA + ICS triple therapy ✓
• C Switch to LAMA monotherapy with azithromycin prophylaxis
• D Initiate long-term oral prednisolone to suppress inflammation

Explanation

Per GOLD 2024, escalation to triple therapy (LAMA + LABA + ICS) is recommended for COPD patients with persistent exacerbations on dual bronchodilator therapy. Blood eosinophil count ≥300 cells/μL is the strongest predictor of ICS response, and this patient's eosinophil count of 450 cells/μL supports ICS addition. The IMPACT and ETHOS trials showed triple therapy significantly reduced exacerbations compared to LAMA+LABA. Roflumilast is an add-on option for patients with chronic bronchitis and FEV1 <50%, specifically targeting neutrophilic inflammation. Long-term oral steroids are contraindicated in COPD due to systemic adverse effects without clear benefit.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.