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Chronic obstructive pulmonary disease — SCE Respiratory MCQ

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HardInhaled TherapyChronic obstructive pulmonary diseaseSCE Respiratory

A 71-year-old man with smoking-related COPD is reviewed after his second hospital admission with radiologically confirmed pneumonia within 10 months. On both occasions, CT showed new lobar consolidation that resolved after antibiotic treatment. Subsequent CT excludes bronchiectasis, an obstructing lesion and persistent infiltrates. He has no history of asthma, atopy or marked symptom variability. Post-bronchodilator FEV1 is 43% predicted, with an increase of 80 mL and 5% from baseline. He stopped smoking 4 years ago and has completed pulmonary rehabilitation. He has used fluticasone furoate/umeclidinium/vilanterol regularly for 2 years with satisfactory inhaler technique. Apart from the pneumonias, he has had no oral corticosteroid-treated or hospitalised COPD exacerbations for 3 years. Blood eosinophil counts obtained during clinical stability, without recent systemic corticosteroid exposure, have been 40, 60 and 70 cells/μL. His breathlessness is stable at mMRC grade 2. Which change to his inhaled treatment is most appropriate?

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

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Correct answer: E — Change directly to a LABA/LAMA regimen, with follow-up of symptoms, lung function and exacerbations

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

This patient is a strong candidate for inhaled corticosteroid withdrawal. He has no asthmatic features, no recent COPD exacerbations and repeatedly very low blood eosinophil counts measured during stability. Conversely, recurrent radiologically confirmed pneumonia represents a clinically important ICS-associated adverse effect. ERS guidance supports ICS withdrawal in COPD without frequent exacerbations, strongly advises against withdrawal when eosinophils are at least 300 cells/μL, and recommends maintaining one or two long-acting bronchodilators after withdrawal. Available withdrawal studies do not establish a need for routine ICS tapering in an otherwise stable patient. A is inappropriate because there is little evidence of ongoing corticosteroid-responsive disease to offset the recurrent pneumonia risk. B reduces exposure but retains the drug class responsible for concern despite a weak indication. C preserves dual bronchodilation while removing ICS and includes the required post-withdrawal monitoring. D removes both ICS and LABA, risking deterioration in breathlessness despite his continuing symptomatic limitation. E is unnecessarily cautious: gradual withdrawal is not routinely required, although monitoring after the change remains important. Severe airflow obstruction alone is not an indication to retain ICS; the decisive variables are exacerbation history, steroid-responsive features, eosinophil count and treatment toxicity.

Reference: Withdrawal of inhaled corticosteroids in COPD: a European Respiratory Society guideline (4 June 2020) — https://publications.ersnet.org/content/erj/55/6/2000351 Chronic obstructive pulmonary disease in over 16s: diagnosis and management (Published 5 December 2018; updated 26 July 2019) — https://www.nice.org.uk/guidance/ng115/chapter/Recommendations