COPD exacerbations in general practice: variability in oral prednisolone courses.

Abstract

The use of oral corticosteroids as treatment of COPD exacerbations in primary care is well established and evidence-based. However, the most appropriate dosage regimen has not been determined and remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-morbidity.
Cross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the Netherlands.
The response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven, ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP adjusted treatment to the presence of diabetic co-morbidity.
Under normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a substantial variation in treatment duration.

Full text

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RESEARCH ARTICLE Open Access
COPD exacerbations in general practice:
variability in oral prednisolone courses
Marianne de Vries1, Annette J Berendsen1*, Henk EP Bosveld1, Huib AM Kerstjens2and Thys van der Molen1
Abstract
Background: The use of oral corticosteroids as treatment of COPD exacerbations in primary care is well
established and evidence-based. However, the most appropriate dosage regimen has not been determined and
remains controversial. Corticosteroid therapy is associated with a number of undesirable side effects, including
hyperglycaemias, so differences in prescribing might be relevant. This study examines the differences between GPs
in dosage and duration of prednisolone treatment in patients with a COPD exacerbation. It also investigates the
number of general practitioners (GPs) who adjust their treatment according to the presence of diabetic co-
morbidity.
Methods: Cross-sectional study among 219 GPs and 25 GPs in training, located in the Northern part of the
Netherlands.
Results: The response rate was 69%. Nearly every GP prescribed a continuous dose of prednisolone 30 mg per
day. Among GPs there were substantial differences in treatment duration. GPs prescribed courses of five, seven,
ten, or fourteen days. A course of seven days was most common. The duration of treatment depended on
exacerbation and disease severity. A course of five days was especially prescribed in case of a less severe
exacerbation. In a more severe exacerbation duration of seven to fourteen days was more common. Hardly any GP
adjusted treatment to the presence of diabetic co-morbidity.
Conclusion: Under normal conditions GPs prescribe prednisolone quite uniformly, within the range of the current
Dutch guidelines. There is insufficient guidance regarding how to adjust corticosteroid treatment to exacerbation
severity, disease severity and the presence of diabetic co-morbidity. Under these circumstances, there is a
substantial variation in treatment duration.
Background
COPD exacerbations have a profound and long lasting
effect on quality of life and the frequency of exacerbations
contributes to long term decline in lung function [1].
Treatment of a COPD exacerbation with oral or parenteral
corticosteroids significantly reduces treatment failure, the
need for additional medical treatment, and shortens hospi-
tal stay. It increases the rate of improvement in lung func-
tion and dyspnoea [2]. However, corticosteroid therapy is
associated with undesirable side effects, especially weight
gain, insomnia and hyperglycaemias [2,3]. The risk of
these side effects depends on dosage and duration [4].
The question is whether the potential benefits of treat-
ment outweigh their risks. Optimum dosage and dura-
tion of treatment are not yet established [2].
Hospitalized patients all receive systemic treatment with
corticosteroids. The Dutch College of General Practi-
tioners (NHG) COPD Guideline recommends home
treatment with prednisolone 30 mg for seven to four-
teen days [5]. There is no guidance regarding how to
adjust treatment to any co-morbidity.
Unclear treatment advice may lead to differences in
dosage and duration of treatment with systemic corti-
costeroids. Because of the side effects, difference in pre-
scribing might be relevant.
We addressed the following research questions:
Are there differences between general practitioners in
the dose and duration of prednisolone treatment in case
of COPD exacerbations?
* Correspondence: a.j.berendsen@umcg.nl
1Department of General Practice, University Medical Centre Groningen,
University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen,
the Netherlands
Full list of author information is available at the end of the article
de Vries et al. BMC Family Practice 2012, 13:3
http://www.biomedcentral.com/1471-2296/13/3
© 2012 de Vries et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.

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Do dosage and duration of prednisolone treatment
depend on exacerbation and disease severity or diabetic
co-morbidity?
Methods
A cross sectional survey using questionnaires was con-
ducted in the Northern part of The Netherlands, distrib-
uted randomly over general practitioners (GPs) and GPs
in training between May and June 2010.
The items of the questionnaire (additional file 1) were
based on the literature and interviews with four experts.
In order to improve the face and content validity, the
concept questionnaire was presented to a number of
senior GPs and GP trainees.
We presented four case scenarios regarding different
patients with an exacerbation of COPD. In case A to D
exacerbation-and disease severity increased.
Case A
A patient with a mild to moderate COPD (GOLD 1/2)
and no severe exacerbation.
Case B
A patient with a mild to moderate COPD (GOLD 1/2)
and a severe exacerbation.
Case C
A patient with a severe to very severe COPD (GOLD
3/4) and no severe exacerbation.
Case D
A patient with a severe to very severe COPD (GOLD
3/4) and a severe exacerbation.
An exacerbation was characterized by ‘a worsening of
patient’s condition within a couple of days, representing
a worsening of dyspnoea and coughing (with or without
sputum) beyond normal day-to-day variations’. This
definition is used in the COPD guideline of the Dutch
College of General Practitioners (NHG). A severe
exacerbation was characterized by dyspnoea at rest,
inability to speak in a full sentence, not able to lay flat,
respiratory frequency above thirty breaths per minute,
heart rate above one hundred twenty beats per minute
and the use of accessory respiratory muscles. The sever-
ity of COPD was defined as per GOLD classification
(table 1). The questionnaire consisted of semi closed
self-completed questions.
Every GP had to give a treatment regimen for each
case supposing that the patient was non-diabetic or dia-
betic, respectively. We choose the co-morbidity diabetes
as this has the highest prevalence of the co-morbidities
influenced by the use of prednisolone. Treatment regime
was characterized by type of schedule (continuous/
tapered), in combination with dosage (mg) and duration
of treatment (days). We created space for comments.
Data were analysed by using SPSS 16.0 and described
by percentages and confidence intervals. A p-value of <
0.05 was considered significant. Ethical approval was not
required.
Results
Respondent characteristics
The study was conducted in May 2010 through to
December 2010. Of the 240 included GPs 73% (n = 174)
returned the questionnaire. A fully completed question-
naire was returned by 147 GPs and 19 GPs trainees (n =
166, 69%). All respondents were working in a general
practice with an average of four days per week (range
0.5-5 days).
Differences in dosage and duration of treatment with
prednisolone
Dosage and duration of treatment
Nearly every GP gave a continuous regimen of predni-
solone 30 mg a day for patients without or with dia-
betes (table 2 and 3; Figure 1 and 2). Among GPs
there were large differences in duration of treatment.
Although a seven- day course was most common,
courses of five, ten, or fourteen days were also fre-
quently prescribed in patients with or without diabetes.
A five- day course was especially prescribed in case of
a mild exacerbation. In more severe exacerbations, GPs
preferred a course of seven, ten, or fourteen days. Only
a few GPs prescribed the same regimen in each case
(9%).
Dependency on exacerbation severity
Patients with a mild and a severe exacerbation were
compared (case A to B and case C to D).
In patients with mild or moderate COPD, 46% of GPs
took exacerbation severity into account. A majority of
GPs gave a higher total dose of prednisolone in case of
a severe exacerbation: on average, 88 mg prednisolone
per treatment regimen more (35%, P < 0.001). Only 11%
of patients received specialist treatment.
71% of GPs declared exacerbation severity to be an
important factor in treating patient with severe or very
severe COPD. In such cases, the majority of GPs pre-
ferred treatment by a pulmonologist (61%). A minority
Table 1 Gold Classification: Global Initiative for
Obstructive Lung Disease
SeverityFEV1
Gold
1
Gold
2
Gold
3
Gold
4
Mild
≥ 80 predicted
Moderate 50-80% predicted
Severe30-50% predicted
Very
severe
≥ 30%, or < 50% predicted and with respiratory
failure
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of patients was given a higher total dose of predniso-
lone: on average, 125 mg per regimen more (10%, P <
0.001).
Dependency on disease severity
Patients with GOLD 1/2 and GOLD 3/4 were compared
(Case A to C and case B to D).
In case of a mild exacerbation, 43% of GPs took into
account disease severity by giving a higher total dose of
prednisolone to patients with severe and very severe
COPD: on average 116 mg prednisolone per treatment
regime more (P < 0.001).
61% of GPs declared disease severity to be an impor-
tant factor in treating patients with a severe exacerba-
tion. Only a few GPs gave a higher total dose of
prednisolone to patients with severe or very severe
COPD. On average this was 118 mg more per treatment
regime (10%, P < 0.001). Half of the GPs preferred treat-
ment in a hospital (51%).
Diabetes mellitus
Patients with and without diabetes mellitus were com-
pared. Few GPs (16%) adjusted their treatment to the
Table 2 Treatment of COPD exacerbations in general practice
Case 1
GOLD 1,2 no severe
exacerbation
DM- [CI]
Case 2
GOLD 1,2 no severe
exacerbation
DM- [CI]
Case 3
GOLD 3,4 severe
exacerbation
DM- [CI]
Case 4
GOLD 3,4 severe
exacerbation
DM- [CI]DM+ [CI]DM+ [CI]DM+ [CI] DM+ [CI]
Choice of treatment
1- Specialist treatment
N = 165
0%
[0.000-0.000]
2%
[0.004-0.052]
N = 161
0%
[0.000-0.000]
5%
[0.022-0.096]
95%
[0.904-0.978]
N = 157
3%
[0.010-0.073]
97%
[0.927-0.990]
N = 149
17%
[0.112-0.238]
57%
[0.487-0.651]
6%
[0.028-0.112]
0%
[0.000-0.000]
N = 164
10%
[0.057-0.154]
0%
[0.000-0.000]
90%
[0.846-0.943]
N = 147
1%
[0.000-0.037]
99%
[0.963-1.000]
N = 143
5%
[0.020-0.098]
57%
[0.488-0.656]
22%
[0.152-0.293]
4%
[0.016-0.089]
N = 159
16%
[0.104-0.223]
0%
[0.000-0.000]
84%
[0.777-0.896]
N = 134
3%
[0.008-0.075]
97%
[0.925-0.992]
N = 128
6%
[0.027-0.119]
61%
[0.519-0.694]
20%
[0.137-0.283]
1%
[0.000-0.043]
N = 166
0%
[0.000-0.000]
0%
[0.000-0.000]
100%
[0.967-1.000]
N = 166
2%
[0.004-0.052]
98%
[0.948-0.996]
N = 160
8%
[0.044-0.135]
58%
[0.501-0.659]
22%
[0.157-0.291]
4%
[0.014-0.080]
N = 158
0%
[0.000-0.000]
1%
[0.002-0.045]
99%
[0.955-0.998]
N = 157
6%
[0.027-0.106]
94%
[0.894-0.973]
N = 141
9%
[0.050-0.153]
59%
[0.503-0.671]
20%
[0.136-0.274]
1%
[0.000-0.039]
N = 158
61%
[0.527-0.684]
0%
[0.000-0.000]
39%
[0.316-0.473]
N = 62
6%
[0.018-0.157]
94%
[0.843-0.982]
N = 57
2%
[0.000-0.094]
44%
[0.307-0.576]
42%
[0.291-0.559]
5%
[0.011-0.146]
N = 156
72%
[0.640-0.787]
0%
[0.000-0.000]
28%
[0.213-0.360]
N = 43
9%
[0.026-0.221]
91%
[0.779-0.974]
N = 38
5%
[0.006-0.177]
42%
[0.263-0.592]
40%
[0.240-0.566]
5%
[0.006-0.177]
2- No treatment
3- Primary care treatment 98%
[0.948-0.996]
N = 162
0%
[0.000-0.000]
100%
[0.966-1.000]
N = 161
13%
[0.083-0.192]
64%
[0.560-0.714]
8%
[0.044-0.134]
0%
[0.000-0.000]
Type of regimen
A) Tapering regimen
B) Continuous regimen
Continuous regimen
30mg for 5 days
30mg for 7 days
30mg for 10 days
30mg for 14 days
DM - = patients without diabetes; DM + = patients with diabetes; CI = 95% confidence interval
Table 3 Percentage of GPs adjusting their treatment in case of diabetic co-morbidity
Case 1
GOLD 1,2 no severe
exacerbation
Case 2
GOLD 1,2, severe
exacerbation
Case 3
GOLD 3,4, no severe
exacerbation
Case 4
GOLD 3,4, severe
exacerbation
Adjustment:
N = 162
1%
11%
3%
0%
CI
[0.001-0.044]
[0.067-0.170]
[0.010-0.071]
[0.000-0.000]
N = 157
1%
14%
0%
5%
CI
[0.002-0.045]
[0.090-0.204]
[0.000-0.000]
[0.022-0.098]
N = 153
2%
14%
1%
0%
CI
[0.004-0.056]
[0.087-0.202]
[0.002-0.046]
[0.000-0.000]
N = 154
0%
2%
0%
10%
CI
[0.000-0.000]
[0.004-0.056]
[0.000-0.000]
[0.056-0.156]
1. Higher total treatment dose
2. Lower total treatment dose
3. No treatment
4. Specialist treatment
No adjustment:
5. Both patients same total treatment dose 83%
6. Both patients no treatment
7. Both patients specialist line treatment
[0.053- 0.148]
[0.004-0.053]
[0.000-0.000]
69%
0%
11%
[0.609-0.759]
[0.000-0.000]
[0.064-0.168]
83%
0%
0%
[0.761-0.886]
[0.000-0.000]
[0.000-0.000]
25%
0%
63%
[0.187-0.330]
[0.000-0.000]
[0.548-0.706]
2%
0%
CI = 95% confidence interval
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presence of diabetic co-morbidity (Table 3; Figure 2). In
case of known diabetes, only 10% prescribed a lower
total dose of prednisolone: case A to D on average
respectively 73 mg (P < 0.001), 94 mg (P < 0.001), 87
mg (P < 0.001) and 66 mg (P < 0.002) prednisolone per
treatment regime less. A few GPs gave no prednisolone
treatment at all in case of a mild exacerbation (case A
and C: 3% and 1%, respectively). Patients with a severe
exacerbation were sometimes sent to hospital because of
their diabetic co-morbidity (case B and D: 5% and 10%,
respectively).
Comments of GPs
The following factors where indicated to influence deci-
sions on treatment regimen: individual treatment experi-
ence and the wish of the patient (n = 15), saturation (n
= 8), home environment (n = 5), fever (n = 4), national
guidelines (n = 2), advice pulmonologist (n = 2), the
type of diabetes (n = 2), fluid intake (n = 1) and the
continuous use of prednisolone (n = 1). Patients with
diabetes administered a course of corticosteroids were
advised to check their blood sugar more often (n = 26).
Discussion
This study shows that GPs in the Netherlands rather
uniformly prescribe a daily dose of 30 mg prednisolone
in the treatment of COPD exacerbations. There is
hardly any difference between GPs in dosage of treat-
ment and with that they strictly seem to follow the
guidelines. On the other hand GPs differed notably in
duration of treatment. These differences in duration of
treatment increased in more serious situations. A small
number of GPs prescribed the same regimen in all case
scenarios. Treatment was often adjusted to exacerbation
and disease severity. This even determined the choice
between treatment with or without consultation of a
pulmonologist. Of note, few GPs adjusted their treat-
ment to the presence of diabetic co-morbidity.
GPs reported the important influence of an earlier,
successful individual treatment experience as well as
the patients wish on choice of treatment regimen. It is
conceivable that GPs management (working hours,
local appointments, coded prescriptions and prescrib-
ing according to an electronic prescription system) as
well as regional, national and international guidelines
play a role in prescribing a particular treatment
regimen.
Dutch GPs often follow the guidelines as issued by the
NHG. These guidelines are evidence based, comprehen-
sive, and the conclusions are published for all diseases
in the same format. Currently guidelines are available
for 99 different diseases among which COPD. The Sec-
ond Dutch National study showed that GPs followed
76% of the recommendations [6]. Treatment advice was
followed by 62% [6]. In our current study nearly every
GPs declares to prescribe a continuous treatment regi-
men de facto according to the Dutch COPD guideline
(96%). 80% of GPs followed the advised dosage and
duration of treatment. The number of GPs practising
according to the Dutch COPD guideline is therefore
even higher than expected compared to the Second
Dutch National Study.
The level of compliance with the guidelines is high
even though there is hardly any evidence to support it.
The regimen (30 mg prednisolone for 7-14 days) is also
common internationally (table 4) [2,7-21]. A couple of
studies comparing corticosteroid treatment with placebo
treatment, showed a number of beneficial effects on
FEV1 improvement, days of hospitalisation [7,8] and
time to second exacerbation [9]. Only two studies were
found regarding treatment duration [8,10]. In the first
study, a course of 8 weeks was no more effective than a
course of two weeks [8]. In the second study, a course
of 10 days was more effective than a course of three
days [10]. No head to head comparisons of different
dosages were found. Randomised clinical trials (RCTs)
using higher dosages did not achieve better results than
RCTs using lower dosages [7-9]. The current policy to
reject the tapering regimen is based on an old study in
patients with an asthma exacerbation [16].
0
10
20
30
40
50
60
70
Case 1 N=61 Case 2 N= 143Case 3 N= 160Case 4 N= 57
30 mg 5 days
30 mg 7 days
30 mg 10 day
30 mg 14 days
Figure 1 Most common treatment regimens for COPD patients
without diabetes.
0
10
20
30
40
50
60
70
Case 1 N= 149Case 2 N= 128 Case 3 N= 141 Case 4 N= 38
30 mg 5 days
30 mg 7 days
30 mg 10 days
30 mg 14 days
Figure 2 Most common treatment regimens for COPD patients
with diabetes.
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It is interesting that few studies showed some benefi-
cial effects of inhalation corticosteroids, whether or not
combined with a long acting beta-2-agonist, in compari-
son with prednisolone [12-15].
With all these uncertainties it is not surprising that
there is no guidance regarding how to adjust treatment
to exacerbation and disease severity or to the presence
of diabetic co-morbidity. Many GPs tend to prescribe a
higher dose or longer treatment duration in case of a
severe exacerbation or severe COPD. However again,
evidence based regimes are missing. It is only known
that oral prednisolone is not less effective than intrave-
nous prednisolone [11].
Just like other international guidelines, the Dutch
Guideline does not provide guidance how to prescribe
in case of diabetic co-morbidity. However, dose and
duration of treatment strongly determine the risk of side
effects [4]. In nearly every patient with known diabetes,
corticosteroids exacerbate hyperglycaemia [22]. Besides
approximately 50% of patients without known diabetes,
treated with 20 mg prednisolone a day, develop hyper-
glycaemia (> 11.1 mmol/l) within 24 hours [23]. So,
many patients have to deal with steroid induced hyper-
glycaemia. This is not without risk. Fluctuations in
plasma glucose concentrations have been associated
with increased cardiovascular mortality [22]. Moreover,
three or more corticosteroid treatments per year are
associated with an odds ratio of 1.36 for the develop-
ment of new onset diabetes [22].
The same treatment regimen was routinely applied to
patients with or without diabetes mellitus. There is no
evidence to support different doses, largely because
there is no evidence at all. Perhaps clinicians feel that
some loss of glucose control is not as serious as an
inadequately treated exacerbation of COPD. Of the GPs
26 (16%) commented spontaneously that they advised
their diabetic patients to check their blood sugar more
often. An alternative for patients with diabetes could be
to check their glucose levels daily preferably until a
couple of days after finishing their treatment. It may be
easier for patients on insulin to measure their blood
sugar and adjust their insulin accordingly, while those
on oral agents have less ability to do so.
Apart from hyperglycaemia there are important other
side effects of the treatment with corticosteroids: in par-
ticular endocrine, neurological, psychiatric, ophthalmic
and gastrointestinal side effects. There are also side
effects of the musculoskeletal system, metabolism and
electrolyte balance. Dosage and duration of treatment
again determine the risk of these side effects [4]. For
most of the side effects it is not exactly known at which
dosage they occur. Side effects as fluid retention, hyper-
tension and heart failure can occur directly after starting
prednisolone treatment. Psychiatric disturbances as
depression, mania, anxiety, and psychosis may occur
within the first week [24]. Even short term, low dose
systemic steroids exposes the patient to the risk of adre-
nal insufficiency [25]. A well-known long term compli-
cation is osteoporosis [26,27]. Many patients with
COPD receive treatment with prednisolone several
times a year. The cumulative dose of corticosteroids
strongly correlates with vertebral fracture risk due to
loss of bone mineral density [27].
Because of the short term side effects and the possible
(cumulative) risks, total steroid exposition should be
kept as low as possible. In patients with a COPD exacer-
bation, treatment should be as short as possible with the
dosage prednisolone as low as possible. In patients with
an asthma exacerbation a short course (3-5 days) of pre-
dnisolone has been shown to be effective [28,29].
More research should establish the optimum dose and
duration of corticosteroid treatment. Research should
also be directed at determining how to adjust corticos-
teroid treatment to exacerbation severity, disease sever-
ity and the presence of diabetic co-morbidity. Until then
the best we can do is to follow the current guideline
that recommends prednisolone 30 mg for seven to four-
teen days.
Table 4 National- and international guidelines: corticosteroid treatment in case of COPD exacerbation
Guideline Recommendation
NHG- guideline COPD 2007
CBO guideline 2010:
Diagnostics and treatment of COPD
• Prednisolone 30 mg once a day for 7-14 days.
• Prednisolone 30 mg once a day for 7-14 days.
• Prefer oral prednisolone treatment.
• Blood sugar check for patients with diabetes.
• Prednisolone 30-40 mg once a day for 7-10 days for patients
with FEV1 < 50%
• Budesonide, whether or not combined with formoterol may
be an alternative to prednisolone treatment.
• Prefer oral prednisolone treatment
• 30-40 mg prednisolone once a day for 10 days.
• Consider corticosteroid inhalation therapy.
• Prednisolone 30 mg once a day for 7-14 days.
GOLD guideline 2009 ‘Global Strategy for the Diagnosis, Management, and
Prevention of Chronic Obstructive Pulmonary Disease’
ATS/ERS guideline 2004 ‘Standards for the diagnosis and treatment of patients with
COPD’
Nice guideline 2010: ‘Chronic obstructive pulmonary disease: Management of
chronic obstructive pulmonary disease in adults in primary and secondary care’.
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Limitations of this study: Only GPs and GPs in train-
ing living in the North of Holland were approached.
The response rate on the other hand was high (69%).
We did not want to increase the number of questions
as this could influence the response rate. Therefore we
decided to focus on dose and duration of prednisolone
treatment, despite the recommendation of the Dutch
guideline to double patient’s dose of bronchodilators or
to use a combination of two different bronchodilators in
case of an non-severe exacerbation. Because diabetes is
the most common co-morbidity, we only asked for an
alternative regimen if the patient had diabetes. We did
not make a difference for those on oral agents or on insu-
lin. We did not focus on a possible concomitant therapy
with antibiotics and we did not ask for the date of the
last treated exacerbation. There may be a social desirabil-
ity bias. However, the questionnaire does not concern a
sensitive subject. Furthermore, assessing a patient on
paper is not like assessing a patient in real life. It is likely
that some GPs do not use a standard approach, resulting
in less representative answers. We tried to solve this by
offering an opportunity for comments.
Conclusions
Under normal conditions GPs prescribe prednisolone
quite uniform, within the range of the current guideline
of the Dutch College of General Practitioners. There is
insufficient guidance regarding how to adjust corticos-
teroid treatment to exacerbation severity, disease sever-
ity and the presence of diabetic co-morbidity. Under
these circumstances, there is a substantial variation in
treatment duration.
Additional material
Additional file 1: The questionnaire - the items.
Abbreviations
COPD: Chronic obstructive pulmonary disease; GP: General Practitioner;
GOLD: Global Initiative for Obstructive Lung Disease; NHG: Dutch College of
general practitioners; RCT: Randomised clinical trial.
Acknowledgements and funding
We wish to thank all GPs who participated in the study.
The authors received no funding for this study.
Author details
1Department of General Practice, University Medical Centre Groningen,
University of Groningen, Antonius Deusinglaan 1, FA 20, 9700 AD Groningen,
the Netherlands.2Department of Pulmonology, University Medical Centre
Groningen, University of Groningen, PO Box 30.001, 9700 RB Groningen, the
Netherlands.
Authors’ contributions
MV contributed substantially to the design and acquisition of data and
drafted and edited the manuscript. AJB, HAM, and TM were involved in
designing the study, supervising its execution and in drafting the
manuscript as well as revising the manuscript critically. HEP carried out the
data extraction. All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 October 2011 Accepted: 12 January 2012
Published: 12 January 2012
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Cite this article as: de Vries et al.: COPD exacerbations in general
practice: variability in oral prednisolone courses. BMC Family Practice
2012 13:3.
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