We have read the latest version of the Spanish guidelines on COPD (GesEPOC), published recently (January 2014) in Archivos de Bronconeumología.1 When the AUDIEPOC study was published in July 2012, we observed that there was little homogeneity in the management of COPD exacerbation at the national level.2 A more rigorous review of the published data revealed that this variability also exists in the use of systemic corticosteroids during exacerbations. In the 2014 update, GesEPOC clinical guidelines propose a change in systemic corticosteroid treatment during exacerbations. Thus, the original version recommended a short course of 7–10 days,3 while in the 2014 update, the guidelines support the use of “short 5-day courses for […] exacerbations that do not require hospitalization”.

We believe that this change is based essentially on data from the REDUCE clinical trial,4 which compared treatment with a short 5-day course of 40mg of prednisone versus a 14-day course during exacerbations. The trial showed a similar reexacerbation rate, with the advantage of lower exposure to corticosteroids and very similar findings as regards outcomes (hospital stay and deaths).

We agree that exacerbations can be managed with lower doses and shorter treatment times than those used in routine clinical practice. At the same time, we consider that this conclusion, currently limited by the guidelines to outpatients, could also be extended to some patients with more severe exacerbations who require hospital admission. In the REDUCE clinical trial, of the 314 patients who attended the Emergency Department (311 evaluated) and were randomized to receive a short or long corticosteroid regimen, 289 (92%) patients were admitted to hospital. The groups were adequately balanced with respect to COPD severity (GOLD 2, 3 and 4 in both groups) and clinical presentation (vital signs, oxygenation on admission, leukocytosis).

The meta-analysis published by Cheng et al.5 also reinforces the hypothesis that lower doses of corticosteroids (30–80mg of prednisolone for 5 days) can be safely used in inpatients with COPD exacerbation.

This meta-analysis and the REDUCE clinical trial are perhaps the only studies to support short in-hospital regimens, and further research will probably be required to confirm this in special populations (e.g. patients with persistent bronchospasm). However, we consider that GesEPOC guidelines should include this patient population, and indicate that this treatment regimen is not limited to outpatients treated for COPD exacerbation.