These recommendations are based on expert opinion in the the National Institute for Health and Clinical Excellence (NICE) clinical guideline Management of chronic obstructive pulmonary disease (COPD) in adults in primary and secondary care (partial update) [National Clinical Guideline Centre, 2010; NICE, 2010].

• NICE identified a meta-analysis of 10 randomized controlled trials that compared oral corticosteroids with placebo. However, NICE concluded that owing to methodological limitations, this study did not establish the effects of sustained oral corticosteroid treatment on either forced expiratory volume in 1 second (FEV₁) or more patient-oriented clinical outcomes. The study also did not establish the potential long-term adverse effects of sustained treatment.
• On the basis of the opinion of the guideline development group, NICE concluded that:
• No published studies were found that establish which people with COPD, if any, benefit from long-term oral steroid therapy.
• There is a small group of people who experience frequent exacerbations or severe breathlessness for whom long-term oral steroid treatment is the only pragmatic management.
• Some people with advanced COPD may require maintenance oral corticosteroids when these cannot be withdrawn following an exacerbation.
• NICE did not update the evidence on oral corticosteroids for stable COPD; CKS identified a subsequent Cochrane systematic review of 24 randomized controlled trials [Walters et al, 2005]. Although FEV₁ increased significantly in people taking high-dose oral corticosteroids compared with those taking placebo, there were no clinically important differences in health-related quality of life. The authors concluded that no evidence supports the long-term use of oral corticosteroids at doses of 15 mg or lower, and that potentially harmful adverse effects of higher doses prevent recommending their use.
• The recommendation to refer the person to a respiratory specialist to assess the need for continuing treatment if the person is already taking oral corticosteroids for maintenance treatment that was not started by a specialist is based on what CKS considers to be good clinical practice.
• Recommendations on osteoporosis monitoring and prophylaxis by NICE were based on guidelines from the Royal College of Physicians (RCP) on the prevention and treatment of osteoporosis [RCP, 1999]. The RCP has also published specific guidelines on the prevention and treatment of glucocorticoid-induced osteoporosis [RCP, 2002], which form the basis for the CKS topic on Osteoporosis - preventing steroid-induced.