A 71-year-old man with a 45 pack-year smoking history presents to the clinic for follow-up of his COPD. Over the past 12 months, he has had two moderate exacerbations treated with oral corticosteroids and one hospitalization for an exacerbation. His CAT score is 22 and his mMRC dyspnea grade is 3. His most recent peripheral blood eosinophil count is 180 cells/µL. He is currently using only albuterol (Ventolin) as needed. According to the 2023 GOLD ABE classification, what is the initial pharmacologic therapy of choice?

Question

Accepted Answer

✅ C. Group E — initiate a long-acting beta-agonist (LABA) plus a long-acting muscarinic antagonist (LAMA) combination
The 2023 GOLD update collapsed the prior C and D groups into a single Group E ("Exacerbations"), defined as ≥2 moderate exacerbations OR ≥1 leading to hospitalization in the past year, regardless of symptom burden. This patient meets Group E by both criteria. Recommended initial therapy for Group E is LABA + LAMA (e.g., olodaterol + tiotropium, or umeclidinium + vilanterol). Triple therapy with addition of an inhaled corticosteroid (ICS) is considered when the blood eosinophil count is ≥300 cells/µL — this patient's count is 180, so ICS is not indicated up front.

❌ A. Group A — initiate a short-acting bronchodilator as needed only
Group A is for patients with low symptoms (CAT <10, mMRC 0–1) AND low exacerbation risk. This patient has high symptoms AND high exacerbation risk, ruling out Group A.

❌ B. Group B — initiate a long-acting beta-agonist (LABA) monotherapy only
Group B is for patients with high symptoms (CAT ≥10 or mMRC ≥2) but LOW exacerbation risk (0–1 moderate exacerbations, no hospitalization). Even for Group B, current GOLD now favors LABA + LAMA initial therapy over monotherapy. This patient does not qualify for Group B because of his exacerbation history.

❌ D. Group E — initiate triple therapy with LABA + LAMA + inhaled corticosteroid
Triple therapy as INITIAL therapy in Group E is reserved for patients with eosinophils ≥300 cells/µL. With eosinophils of 180, ICS is not first-line and may increase pneumonia risk without proportionate exacerbation reduction. ICS could be added later if exacerbations persist on LABA + LAMA.

:::important
GOLD 2023 ABE: A = low symptoms, low risk → bronchodilator. B = high symptoms, low risk → LABA + LAMA. E = ≥2 moderate or ≥1 hospitalized exacerbation → LABA + LAMA (add ICS only if eos ≥300).
:::

GOLD ABE

Clinical Context

Practice Questions

Related Mnemonics

Sources

Ready to practice?