A 55-year-old man with COPD (post-bronchodilator FEV1/FVC 0.62, FEV1 48% predicted, two exacerbations in the past year, MRC dyspnoea grade 3) is currently on LAMA monotherapy. According to GOLD 2023 ABCD classification, he is GOLD Group E. What is the recommended treatment escalation?

• A Add ICS to his current LAMA
• B Start oral theophylline for additional bronchodilation
• C Initiate roflumilast as first-line add-on due to high exacerbation history
• D Escalate to LABA + LAMA (dual bronchodilation) as first step; add ICS (LABA + LAMA + ICS) if blood eosinophils ≥ 300/µL ✓

Explanation

GOLD 2023 revised the classification to Group E for patients with ≥ 2 exacerbations or ≥ 1 hospitalisation. For Group E on monotherapy, escalation to dual bronchodilation (LABA+LAMA) is the standard next step. ICS is added as triple therapy when blood eosinophils are ≥ 300/µL or ≥ 100/µL with frequent exacerbations, based on the IMPACT and ETHOS trial data. Theophylline has poor tolerability and evidence; roflumilast is an add-on for chronic bronchitis phenotype not first escalation.

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

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Written and medically reviewed by the StethoPrep medical team.