A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 42% predicted) has been on dual bronchodilator therapy (LABA+LAMA). He has had 3 exacerbations in the past year. Blood eosinophil count is 380/μL. According to GOLD 2024 guidelines, which is the most appropriate therapy escalation?
- A Add inhaled corticosteroid (ICS) to form LABA/LAMA/ICS triple therapy ✓
- B Add theophylline for additional bronchodilation
- C Switch to LABA+ICS combination and discontinue LAMA
- D Start roflumilast (PDE-4 inhibitor) and continue dual bronchodilator
Explanation
Per GOLD 2024 guidelines, in COPD patients with ≥2 moderate exacerbations or ≥1 hospitalization per year AND blood eosinophil count ≥300/μL (or ≥100 with high exacerbation history), escalation to triple therapy (LABA/LAMA/ICS) is recommended. Blood eosinophilia ≥300/μL is the strongest predictor of ICS response in COPD. The TRIBUTE, IMPACT, and ETHOS trials all demonstrated superiority of triple therapy over dual bronchodilator in reducing exacerbations in this population. Roflumilast is considered for chronic bronchitis phenotype with high exacerbation frequency, usually as add-on to LABA/LAMA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.