A 55-year-old man with COPD GOLD Group E (mMRC ≥ 2, CAT ≥ 10, ≥ 2 exacerbations in past year, prior hospitalisation) is currently on LABA + LAMA. He has eosinophil count of 380 cells/µL. Per GOLD 2024 guidelines, which is the most appropriate escalation?

• A Add roflumilast — preferred over ICS regardless of eosinophil count in GOLD Group E
• B Switch to ICS + LABA, removing LAMA due to increased mortality with triple therapy
• C Add ICS to current LABA+LAMA (triple therapy) — particularly recommended when eosinophils ≥ 300 cells/µL ✓
• D Add azithromycin prophylaxis alone as first escalation step in this patient

Explanation

GOLD 2024 recommends escalation from LABA+LAMA to triple therapy (LABA+LAMA+ICS) in patients with frequent exacerbations (≥ 2 moderate or ≥ 1 severe hospitalisation). Blood eosinophil count ≥ 300 cells/µL predicts a greater response to ICS, and GOLD specifically recommends ICS addition when eosinophils ≥ 300. The IMPACT and TRIBUTE trials support triple therapy superiority. Roflumilast is an adjunct for patients with chronic bronchitis phenotype (productive cough, FEV1 < 50%) rather than a preferred substitute. Azithromycin prophylaxis reduces exacerbation frequency but is third-line adjunct.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.