A 55-year-old male smoker (40 pack-years) has COPD. Spirometry shows FEV1/FVC 0.58, FEV1 48% predicted. He has had two exacerbations requiring systemic steroids in the past year and reports frequent breathlessness (mMRC grade 3). Blood eosinophil count is 350/µL. Per GOLD 2023 guidelines, which maintenance inhaler strategy is most appropriate?
- A Triple therapy: ICS + LABA + LAMA ✓
- B LAMA monotherapy (tiotropium)
- C ICS + LABA combination (e.g., fluticasone/salmeterol)
- D LABA monotherapy (salmeterol)
Correct answer: A. Triple therapy: ICS + LABA + LAMA
Explanation
This patient is GOLD group E (frequent exacerbations) with high symptom burden and an eosinophil count ≥300/µL, which predicts benefit from ICS. GOLD 2023 recommends initial triple therapy (ICS+LABA+LAMA) for GOLD group E patients, particularly those with eosinophils ≥300/µL (IMPACT and ETHOS trials demonstrated superiority of triple therapy over dual therapy in reducing exacerbations). LAMA monotherapy is appropriate for low-risk patients. ICS+LABA without LAMA is suboptimal given the high exacerbation burden.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.