A 62-year-old man with a 40 pack-year smoking history presents with worsening dyspnea and productive cough. Spirometry shows FEV1/FVC of 0.58 (post-bronchodilator), FEV1 42% of predicted. He has had two exacerbations in the past year requiring oral steroids. According to GOLD 2023 classification, which pharmacological therapy is MOST appropriate for long-term maintenance?

• A Short-acting beta-agonist (SABA) alone as needed
• B LABA + LAMA combination inhaler ✓
• C Inhaled corticosteroid (ICS) monotherapy
• D Theophylline as first-line maintenance

Explanation

This patient has GOLD Grade 3 (FEV1 30–50%) COPD with two exacerbations in a year, placing him in Group E (high symptom + high exacerbation risk). GOLD 2023 recommends dual bronchodilation with LABA + LAMA as the cornerstone; triple therapy (LABA + LAMA + ICS) is considered if blood eosinophils ≥ 300 cells/µL or if exacerbations persist. ICS monotherapy is not recommended in COPD as it does not reduce mortality and increases pneumonia risk. SABA alone is inadequate for Grade 3 disease with frequent exacerbations. Theophylline has a poor benefit-to-toxicity ratio and is a last-line agent.

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

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.