A 64-year-old smoker with COPD (GOLD Group E: high symptoms, high exacerbation risk, eosinophil count 380 cells/μL) is on LABA + LAMA (dual bronchodilation). He has had 2 exacerbations requiring hospitalisation in the past year. What is the most evidence-based next step?
- A Add inhaled corticosteroid (triple therapy: ICS + LABA + LAMA) ✓
- B Add theophylline as third bronchodilator
- C Switch LAMA to roflumilast
- D Add long-term oral corticosteroids
Correct answer: A. Add inhaled corticosteroid (triple therapy: ICS + LABA + LAMA)
Explanation
GOLD 2024 guidelines recommend escalation to triple therapy (ICS + LABA + LAMA) for Group E COPD patients who continue to exacerbate on dual bronchodilation, particularly when blood eosinophil count ≥300 cells/μL strongly predicts ICS response. The IMPACT trial demonstrated superiority of triple therapy over dual therapy in reducing exacerbations. Theophylline has a poor safety profile and limited efficacy. Roflumilast is an add-on for chronic bronchitic phenotype, not a LAMA replacement. Long-term oral steroids cause systemic toxicity without sustained benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.