A 60-year-old man with COPD (FEV1 38% predicted, CAT score 22, 3 exacerbations in the past year) on LAMA + LABA still has frequent exacerbations. Blood eosinophil count is 380 cells/µL. According to GOLD 2024 guidelines, the most appropriate add-on therapy is:
- A Azithromycin 250 mg daily without any change to inhaler regimen
- B Inhaled corticosteroid (ICS) addition to triple therapy (ICS-LABA-LAMA) ✓
- C Oral theophylline
- D Roflumilast in all exacerbation-prone patients regardless of eosinophil count
Explanation
GOLD 2024 recommends triple therapy (ICS + LABA + LAMA) for COPD patients with blood eosinophils ≥300 cells/µL who continue to exacerbate on dual bronchodilator therapy, as ICS confers significant exacerbation reduction in this eosinophilic phenotype. An eosinophil count of 380 cells/µL places this patient in a group likely to benefit from ICS. Azithromycin prophylaxis is an option for ex-smokers but is not the primary next step here. Theophylline has limited modern evidence. Roflumilast (PDE4 inhibitor) is indicated specifically for chronic bronchitis phenotype with FEV1 <50% and frequent exacerbations, preferably as add-on to triple therapy in bronchitis-predominant disease.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.