A 65-year-old smoker (40 pack-years) has FEV1/FVC 0.62, FEV1 48% predicted. He has had 3 exacerbations in the past year, with 1 requiring hospitalization. He is on LABA + LAMA. According to GOLD 2023 guidelines, which escalation in pharmacotherapy is most appropriate?
- A Add inhaled corticosteroid (ICS) to existing LABA + LAMA ✓
- B Add oral theophylline
- C Switch LABA to short-acting beta-agonist (SABA) only
- D Add roflumilast if FEV1 >50% predicted
Correct answer: A. Add inhaled corticosteroid (ICS) to existing LABA + LAMA
Explanation
This patient is GOLD Group E (FEV1 <50%, ≥2 exacerbations or ≥1 hospitalization). Despite triple therapy being the goal, stepping up from LABA+LAMA to LABA+LAMA+ICS is recommended if blood eosinophil count ≥300 cells/µL, or ≥100 cells/µL with frequent exacerbations. GOLD 2023 recommends ICS addition to LABA+LAMA for such patients. Roflumilast (PDE4 inhibitor) is indicated as add-on for FEV1 <50%, chronic bronchitis phenotype, and frequent exacerbations — it does not improve outcomes when FEV1 >50%. Theophylline has limited evidence and significant toxicity.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.