A 65-year-old male smoker with COPD (GOLD Stage 3 — severe, GOLD Group E) has two exacerbations in the past year despite triple therapy (LABA+LAMA+ICS). Blood eosinophil count is 320 cells/μL. Which additional therapy is MOST appropriate?
- A Add mepolizumab (anti-IL-5 monoclonal antibody) ✓
- B Add theophylline
- C Add azithromycin long-term
- D Switch ICS to budesonide/formoterol only
Explanation
Mepolizumab (anti-IL-5) was approved by FDA in 2021 for COPD with eosinophilic inflammation (blood eosinophils ≥300 cells/μL) in patients with exacerbations despite maximal inhaler therapy, following the METREX/METREO and subsequent trials. In patients with eosinophil counts ≥150–300 cells/μL who remain symptomatic on triple therapy, mepolizumab reduces moderate-severe exacerbations. Long-term azithromycin is also evidence-based for frequent exacerbators but is second-line and requires QTc monitoring. Theophylline has minimal evidence and significant toxicity in modern COPD management.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.