A 60-year-old smoker has a persistent cough and a BMI of 22. Spirometry shows FEV1/FVC 0.62 and FEV1 55 percent predicted after bronchodilator. What is the first-line long-term inhaled therapy if he has no asthmatic features?

Answer and explanation

Correct answer: D. A long-acting muscarinic antagonist combined with a long-acting beta agonist

  1. Step 1: Obstructive spirometry confirms COPD.
  2. Step 2: NICE NG115 recommends LABA plus LAMA for those without asthmatic features who remain breathless despite a short-acting bronchodilator.
Answer
A long-acting muscarinic antagonist combined with a long-acting beta agonist.
Why not the others: Long-term home oxygen from the first visit, whatever his saturations at rest: Oxygen is for chronic hypoxaemia, not first line. Regular oral prednisolone 5 mg daily to reduce airway inflammation over the long term: Oral steroids cause harm over the long term. A short-acting beta agonist alone, increased to the maximum dose as needed: SABA alone is for mild symptoms only.

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