A 64-year-old male smoker (45 pack-years) with COPD (FEV1 42% predicted, ≥ 2 exacerbations in the past year, mMRC dyspnoea score 3) is on LABA + LAMA. His blood eosinophil count is 350 cells/µL. According to GOLD 2024 recommendations, what therapy should be added?
- A Roflumilast (PDE-4 inhibitor) added to current dual bronchodilator therapy
- B Inhaled corticosteroid (ICS) added to LABA + LAMA (triple therapy) ✓
- C Azithromycin 250 mg three times weekly for exacerbation prevention
- D Theophylline as an add-on bronchodilator
Explanation
GOLD 2024 recommends considering ICS addition to LABA + LAMA (escalating to triple therapy) when blood eosinophil count is ≥ 300 cells/µL in patients with frequent exacerbations, as higher eosinophil counts predict greater benefit from ICS. This patient has blood eosinophils of 350/µL and ≥ 2 exacerbations/year — a strong indication for triple therapy. Roflumilast (PDE-4 inhibitor) is indicated in severe COPD with chronic bronchitis phenotype and frequent exacerbations but is a second-line add-on. Azithromycin prophylaxis is an alternative for frequent exacerbators who are non-smokers (reduces efficacy in smokers and risks QTc prolongation and macrolide resistance). Theophylline is rarely used due to narrow therapeutic index.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.