Stable COPD escalation — SCE Respiratory MCQ

Correct answer: D — Add a LABA to form dual bronchodilator therapy

This woman has symptomatic, spirometrically confirmed COPD despite smoking cessation, pulmonary rehabilitation and a LAMA. She has no asthmatic features or features suggesting steroid responsiveness, and her eosinophil count is low (0.08 × 10^9/L = 80 cells/µL). UK NICE guidance recommends LAMA + LABA dual long-acting bronchodilator therapy for people with COPD who remain breathless or have exacerbations after optimised non-pharmacological management and who do not have asthmatic/steroid-responsive features. Therefore the appropriate step is to add a LABA to her LAMA. Inhaled corticosteroids are not used as monotherapy in COPD and are mainly reserved for asthmatic/steroid-responsive features or escalation after dual therapy in selected patients; she has had only one moderate exacerbation, not the usual threshold for escalation to triple therapy. Long-term oral prednisolone is not normally recommended in stable COPD. Prophylactic azithromycin is considered only after optimised inhaled therapy and specialist-type assessment in patients with frequent/prolonged or hospitalisation-associated exacerbations, particularly with sputum production. Switching from a long-acting LAMA to short-acting ipratropium would be a step down and would not address persistent symptoms.

Reference: NICE Guideline NG115. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Published 2018, last updated 2019; recommendations on inhaled combination therapy and oral prophylactic antibiotic therapy. https://www.nice.org.uk/guidance/ng115/chapter/Recommendations