A 65-year-old ex-smoker with COPD has FEV1/FVC 0.58, FEV1 42% predicted (GOLD Stage 3). He has had 2 exacerbations requiring oral steroids and 1 hospitalization in the past year. CAT score is 26. According to GOLD 2023 guidelines, which inhaler therapy is recommended as initial pharmacological treatment?
- A LABA + LAMA (dual bronchodilator combination) ✓
- B LABA alone (salmeterol)
- C LAMA alone (tiotropium)
- D LABA + ICS (inhaled corticosteroid combination)
Explanation
GOLD 2023 guidelines revised the ABCD assessment to ABC (A, B, E — where E replaces C and D based on exacerbation history). This patient falls in GOLD Group E (≥2 moderate exacerbations or ≥1 hospitalization) with high symptom burden (CAT ≥10). For Group E, initial therapy is LABA+LAMA or LABA+ICS. However, GOLD 2023 specifically recommends considering blood eosinophil count: if eosinophils ≥300 cells/µL, add ICS to LABA+LAMA. The IMPACT and ETHOS trials support triple therapy (LABA+LAMA+ICS) in symptomatic patients with exacerbations and elevated eosinophils. LABA+LAMA (dual bronchodilator) is the backbone initial therapy for Group E when eosinophil count does not indicate ICS benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.