A 65-year-old smoker with COPD (FEV1/FVC <0.70, post-bronchodilator FEV1 45% predicted) has had 2 exacerbations in the past year and CAT score 22. According to GOLD 2023 guidelines, what is the preferred initial maintenance therapy?

• A LABA monotherapy
• B ICS + LABA (if blood eosinophils ≥300 cells/µL) ✓
• C LAMA monotherapy
• D LABA + LAMA dual bronchodilation

Explanation

According to GOLD 2023, patients are categorized as Group E if they have frequent exacerbations (≥2 moderate or ≥1 leading to hospitalization). For Group E patients, initial treatment is LABA + LAMA; however, ICS should be added (triple therapy or ICS+LABA) if blood eosinophils are ≥300 cells/µL, as this predicts corticosteroid responsiveness. With CAT ≥10 (22 here) and 2 exacerbations, this is GOLD Group E; blood eosinophil count guides the decision to add ICS. The IMPACT and ETHOS trials demonstrated benefit of triple therapy (ICS+LABA+LAMA) in exacerbation-prone patients with high eosinophils.

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

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Written and medically reviewed by the StethoPrep medical team.