A 68-year-old male with COPD (GOLD Group B) is experiencing persistent dyspnea. He is currently using a salbutamol inhaler as needed and tiotropium 18 mcg once daily. He uses his salbutamol 4-5 times per day. His FEV1 is 65% predicted. Which of the following additions would be most appropriate according to CTS guidelines?

Question: A 68-year-old male with COPD (GOLD Group B) is experiencing persistent dyspnea. He is currently using a salbutamol inhaler as needed and tiotropium 18 mcg once daily. He uses his salbutamol 4-5 times per day. His FEV1 is 65% predicted. Which of the following additions would be most appropriate according to CTS guidelines?

Answer options:

• Add a low-dose inhaled corticosteroid (ICS).
• Switch tiotropium to salmeterol.
• Add formoterol 12 mcg twice daily. ✅ Switch to a combination inhaler containing a LAMA/LABA.

Correct answer: Switch to a combination inhaler containing a LAMA/LABA.

Explanation: For patients with persistent symptoms (e.g., high SABA use) on a LAMA monotherapy, the next step in GOLD Group B is typically to escalate to dual bronchodilator therapy (LAMA+LABA combination). ICS is generally reserved for patients with a history of exacerbations and high eosinophil counts, or more severe disease (GOLD D with exacerbations).