Editorial
Clinical practice guidelines: To follow them or not
Guías de práctica clínica: seguirlas o no seguirlas
R. Boixeda
Servicio de Medicina Interna, Hospital de Mataró, Mataró, Barcelona, Spain
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Boixeda" "autores" => array:1 [ 0 => array:3 [ "nombre" => "R." "apellidos" => "Boixeda" "email" => array:1 [ 0 => "rboixeda@csdm.cat" ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Interna, Hospital de Mataró, Mataró, Barcelona, Spain" "identificador" => "aff0005" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Guías de práctica clínica: seguirlas o no seguirlas" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Chronic obstructive pulmonary disease (COPD) is an underdiagnosed disease with high morbidity and mortality. It represents a major public health problem and is currently the fourth leading cause of death. In addition, its prevalence is expected to increase as the population ages.</p><p id="par0010" class="elsevierStylePara elsevierViewall">COPD is a complex, multicomponent disease. Its main symptoms include cough, expectoration, and dyspnea. Exacerbation is the prognostic factor that is a therapeutic target in current clinical trials.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Recommendations and clinical practice guidelines (CPG) intend to help physicians during the disease diagnosis and treatment process: any patient with COPD should receive appropriate medical care according to the principles of medicine based on scientific evidence.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Since 2009, the COPD Strategy<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> multidisciplinary team has led the development of CPG with the participation of all its members. In this context, the first version of the Spanish COPD Guidelines (GesEPOC, for its initials in Spanish) emerged in 2012.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In general, the most commonly used guidelines are the <span class="elsevierStyleItalic">Global Initiative for Obstructive Lung Diseases</span> (GOLD) recommendations for the diagnosis and treatment of COPD, which were first published in 2001 and are revised each year.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Nevertheless, the incorporation of CPG recommendations into daily clinical practice tends to be slow and, as a result, a gap between what is recommended in writing and what is done in habitual clinical practice has repeatedly been documented in the past. Recently, in the case of COPD, various studies have demonstrated failure to comply with what is indicated in addition to different ways of proceeding among professionals. In the end, all of this results in a highly disparate care.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The EPOCONSUL study<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> is the first national audit that analyzed COPD care in pulmonology departments in Spain. EPOCONSUL confirmed a high degree of implementation of GesEPOC in its 2012 version: 46.3% of medical records audited included classification of the phenotype, as per the GesEPOC, though there was considerable variation among the different hospitals that applied the good clinical practice recommendations.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In this issue of <span class="elsevierStyleItalic">REVISTA CLÍNICA ESPAÑOLA</span>, Portolés-Callejón et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> have published the article “Adequacy and prognostic impact of treatment for severe exacerbations of chronic obstructive pulmonary disease.” In their work, they evaluated compliance with CPG recommendations with the objective of learning its impact on patient prognosis. A total of 108 patients admitted for COPD exacerbations were included in the study. They found a compliance rate with CPG of 63% in regard to the clinical evaluation. In terms of treatment, it found a compliance of 26.9% to GOLD and 28.7% to GesEPOC. Compliance in terms of the use of corticosteroid treatment was associated with a lower long-term readmission rate and lower mortality both in the hospital and at 3 months.</p><p id="par0040" class="elsevierStylePara elsevierViewall">This is the first study in Spain which analyzes compliance with the guidelines in patients admitted to pulmonology and internal medicine departments for an exacerbation of COPD and its impact on the disease’s prognosis. It demonstrates how following guidelines influences readmissions and mortality. In particular, it demonstrates the importance of compliance with guidelines in regard to systemic corticosteroid therapy.</p><p id="par0045" class="elsevierStylePara elsevierViewall">A systematic review has demonstrated that the use of corticosteroids in patients who require hospital admission for an exacerbation of COPD decreases the rate of treatment failure at 30 days and the length of hospital stay, but is also associated with adverse effects, such as hyperglycemia.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Currently, all CPG on the management of COPD recommend the use of systemic corticosteroids in severe exacerbations at a maximum dose of 0.5 mg/kg/day for 5 days.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Despite the recommendations, recent studies have demonstrated that in habitual clinical practice, the corticosteroid dose recommended in the CPG is tripled; this is associated with a longer hospital stay.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> In fact, a dose greater than 40 mg per day of prednisone in patients hospitalized for a COPD exacerbation is not associated with a shorter hospital stay, a decrease in readmissions, or a decrease in 3-month mortality.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">These results should reinforce the importance of knowledge of the CPG and the impact their application has on the patients we treat.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Boixeda R. Guías de práctica clínica: seguirlas o no seguirlas. Rev Clin Esp. 2020;220:442–443.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Plan de Calidad para el Sistema Nacional de Salud" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "Estrategia en EPOC del Sistema Nacional de Salud" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2009" "editorial" => "Ministerio de Sanidad y Política Social" "editorialLocalizacion" => "Madrid" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guía española de la EPOC (GesEPOC). 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