A 52-year-old male smoker with COPD has FEV1 42% predicted, at least two exacerbations per year despite LABA+LAMA therapy, and blood eosinophil count of 340 cells/μL. What is the MOST appropriate escalation per GOLD 2023 guidelines?
- A Add roflumilast to existing LABA+LAMA
- B Add inhaled corticosteroid (ICS) to form triple therapy ✓
- C Switch to oral prednisolone 5 mg daily
- D Add long-term azithromycin prophylaxis
Explanation
GOLD 2023 guidelines recommend adding ICS to LABA+LAMA (triple therapy) in COPD patients with two or more exacerbations per year AND blood eosinophils ≥300 cells/μL or ≥100 cells/μL with prior hospitalisation. This patient meets both criteria. Triple therapy (e.g., BDP/formoterol/glycopyrronium or FF/VI/umeclidinium) has demonstrated a 25% reduction in exacerbations in the IMPACT and ETHOS trials. Roflumilast is reserved for patients with chronic bronchitis (productive cough) and FEV1 <50%. Long-term macrolides are considered in non-smokers who continue to exacerbate.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.