A 55-year-old man with COPD (FEV1/FVC 0.58, FEV1 42% predicted) has had 3 exacerbations in the past year despite maximal inhaled therapy (LABA + LAMA + ICS). He has peripheral eosinophilia of 340 cells/µL. What add-on therapy is most appropriate to reduce future exacerbations?

• A Oral prednisolone (long-term maintenance)
• B Dupilumab (anti-IL-4Rα)
• C Mepolizumab (anti-IL-5)
• D Roflumilast (PDE-4 inhibitor) ✓

Explanation

Roflumilast (a PDE-4 inhibitor) is indicated as add-on to bronchodilators in severe COPD (FEV1 <50%) with chronic bronchitis and frequent exacerbations (≥2/year), reducing exacerbations by ~15–20%. While eosinophilia may suggest steroid responsiveness, mepolizumab's benefit in COPD is modest and still emerging; it is not a standard add-on. Dupilumab is approved for severe eosinophilic asthma, not COPD (though under study). Long-term oral steroids are avoided in COPD due to myopathy and infection risk.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.