A 55-year-old smoker with GOLD stage 3 COPD (FEV1 38% predicted, CAT score 22, 3 exacerbations in the last year, on dual LABA/LAMA) presents for optimisation. What is the most appropriate next step per GOLD 2024 guidelines?
- A Add roflumilast if FEV1 < 50% and chronic bronchitis phenotype
- B Switch to high-dose ICS monotherapy
- C Add inhaled corticosteroid to the dual bronchodilator (triple therapy) ✓
- D Add azithromycin prophylaxis as first escalation
Correct answer: C. Add inhaled corticosteroid to the dual bronchodilator (triple therapy)
Explanation
Per GOLD 2024, group E patients (CAT ≥10 or mMRC ≥2 with ≥2 exacerbations/year or ≥1 hospitalisation) failing dual LABA/LAMA should be escalated to triple therapy (LABA+LAMA+ICS), particularly when eosinophils ≥300 cells/µL (IMPACT, ETHOS trials). Roflumilast is an add-on for frequent exacerbators with chronic bronchitis and FEV1 <50%, but after triple therapy escalation. Azithromycin prophylaxis is considered when triple therapy fails.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.