The TORCH trial with salmeterol/fluticasone combination in COPD showed a significant reduction in exacerbations but a non-significant trend toward reduced mortality (p=0.052). The SUMMIT trial subsequently showed that fluticasone furoate/vilanterol in COPD patients at high CV risk did NOT reduce mortality. What is the current GOLD 2024 recommendation for maintenance therapy in GOLD Group E (high exacerbation risk, high symptom burden) COPD?
- A LAMA monotherapy
- B LABA + ICS dual therapy
- C ICS monotherapy for all exacerbation-prone patients
- D LAMA + LABA (dual bronchodilation) as initial therapy; triple therapy (LAMA + LABA + ICS) for persistent exacerbations, especially if eosinophils ≥ 300 cells/μL ✓
Explanation
GOLD 2024 recommends that Group E patients (≥2 exacerbations/year or ≥1 leading to hospitalisation, plus high symptoms) start on LAMA + LABA dual bronchodilation. Triple therapy (LAMA + LABA + ICS) is appropriate if blood eosinophils ≥ 300 cells/μL (where ICS benefit is greatest) or if further exacerbations occur on dual therapy. The ETHOS and KRONOS trials demonstrated triple therapy superiority over dual bronchodilation in reducing exacerbations, particularly with higher eosinophil counts. ICS monotherapy is not recommended due to inferior outcomes compared to LABA or LAMA.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.