A 58-year-old COPD patient (FEV1 42%, GOLD grade 3) has had 2 moderate exacerbations and 1 severe exacerbation requiring hospitalisation in the past year. Blood eosinophil count is 380 cells/μL. He is on LAMA + LABA dual bronchodilator therapy. According to GOLD 2024 guidelines, the MOST appropriate escalation is:
- A Add roflumilast (PDE4 inhibitor)
- B Add azithromycin 250 mg three times weekly
- C Switch to LABA + ICS and add theophylline
- D Add inhaled corticosteroid (ICS) to make LABA + LAMA + ICS triple therapy ✓
Explanation
GOLD 2024 classifies patients with ≥2 moderate exacerbations or ≥1 hospitalisation as high exacerbation risk. Blood eosinophil count ≥300 cells/μL is a strong predictor of ICS benefit. For patients on LAMA+LABA with high exacerbation risk and eosinophils ≥300, escalation to triple therapy (LAMA+LABA+ICS) is recommended. IMPACT, ETHOS, and KRONOS trials demonstrated reduced exacerbation rates with triple therapy versus dual bronchodilators. Roflumilast is added on top of triple therapy in patients with FEV1 <50%, chronic bronchitis, and ongoing exacerbations. Azithromycin is an option but requires consideration of QT prolongation and hearing.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.