the risks of glucocorticoids in perspective
Dixon et al have performed a careful nested case-control study of the risk of non-serious infections associated with glucocorticoid use in elderly RA patients. Their methodology is impeccable, and the limitations of the study are clearly discussed.
Importantly, and to my satisfaction, they stress that confounding by indication cannot be ignored, although they posit that such confounding cannot completely explain the effects found.
My main gripe is with the importance attached to these and other observational studies on the risks of glucocorticoid therapy, compared to the potential benefits (eg. improved quality of life and slowing of the progression of disability), and risks of other treatments. For instance, a revealing sentence at the end of the results section reads as follows:
"Gastric acid-suppressive drug prescription (proton pump inhibitors or H2 blockers) in the 45 days before the index date was associated with an increased risk of NSI (aRR 1.36, 1.30 to 1.43)."
Although not the object of research, this risk is close to double that reported for glucocorticoids. With use of acid-suppression almost endemic above a certain age, it is perhaps legitimate to ask where the focus of our attention should be regarding this common adverse event.