Hospitalized exacerbations are important events in patients with COPD because they are responsible for high costs and have great impact on patient’s symptoms and prognosis. Review of high-quality randomized clinical trials in patients hospitalized for COPD exacerbations has established that systemic steroids significantly reduced treatment failure, were associated with earlier improvement in lung function and dyspnea, and shortened hospital stay. However, beneficial effects of systemic steroids came with high rates of adverse effects (including hyperglycemia), with one extra adverse effect occurring for every six people treated. These conclusions were based on studies that have used various protocols for steroid administration, including studies that used very high doses of steroids and administration of steroids for up to 8 weeks. Subsequent studies have suggested that low-dose steroids (30-40 mg/d) administered orally were not associated with worse outcomes than high-dose intravenous therapy and that a shorter duration (5 days) of oral prednisone was noninferior to 14-day treatment. This led to current recommendations of using low-dose short-term oral steroids in patients hospitalized for COPD exacerbations with the aim of limiting adverse events, which still occurred in approximately one to ten patients. Because results of clinical trials provide only limited information on the individual likelihood of benefiting from or being harmed by a therapy, a more personalized approach of steroid prescription in COPD exacerbation is urgently required, with the aim of limiting steroid prescription to patients who may show high benefits and low rates of adverse effects.