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Chronic obstructive pulmonary disease — MSRA MCQ

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Moderateall topics relevant for this examChronic obstructive pulmonary diseaseMSRA

A 68-year-old man with spirometrically confirmed COPD attends for annual review. He stopped smoking 4 years ago and has completed pulmonary rehabilitation. He uses umeclidinium/vilanterol regularly, has satisfactory inhaler technique and has received recommended vaccinations. During the preceding 12 months, he has had 2 acute exacerbations diagnosed and treated in the community, each requiring oral prednisolone and antibiotics. Neither required hospital admission. He is currently back to baseline, with an MRC dyspnoea score of 2 and no day-to-day symptoms adversely affecting his quality of life. Clinical review confirms that the recent episodes were COPD exacerbations rather than heart failure, pneumonia or another cause. He has no previous asthma diagnosis, atopy or other features suggesting steroid responsiveness. What is the most appropriate pharmacological management now?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: C — Add an inhaled corticosteroid to LAMA+LABA therapy

Explanation lettering: E = shown as A · D = shown as B · A = shown as D · B = shown as E

This man has had 2 moderate COPD exacerbations within 1 year despite optimised LAMA+LABA therapy. NICE advises considering escalation to LAMA+LABA+ICS in this situation, after confirming that the episodes were genuine COPD exacerbations and that non-pharmacological care and inhaler use have been optimised. Those checks have been explicitly satisfied in the stem. A is inadequate because recurrent moderate exacerbations despite dual long-acting bronchodilation meet the threshold to consider triple therapy; another rescue pack does not reduce his future exacerbation risk. B is plausible because inhaled corticosteroids can reduce exacerbations, particularly in people with steroid-responsive features, but withdrawing the LAMA is not the recommended escalation from LAMA+LABA. D misapplies the specific 3-month triple-therapy trial recommended for people on LAMA+LABA whose persistent day-to-day symptoms adversely affect quality of life; this patient’s indication is exacerbation frequency. E is incorrect because roflumilast is a specialist-initiated option for severe COPD with chronic bronchitis and at least 2 exacerbations despite triple inhaled therapy.

Reference: NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Recommendations (2019; links updated March 2025) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Recommendations (2019; links updated March 2025) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations NICE NG115: Chronic obstructive pulmonary disease in over 16s: diagnosis and management — Recommendations (2019; links updated March 2025) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations