title: Determining causation--a case study: adrenocorticosteroids and osteoporosis. Should the fear of inducing clinically important osteoporosis influence the decision to prescribe adrenocorticosteroids?
abstract: It is generally accepted that exogenous adrenocorticosteroids cause clinically important osteoporosis. We have reviewed the evidence regarding causation in two stages: an examination of the strength of the methods used, and an application of five "diagnostic tests" for causation. The methods that have been used to investigate the association are weak: there have been no randomized clinical trials or prospective cohort studies. The measures of bone density used to quantify osteoporosis do not bear a close relation to clinically important outcomes. Nine analytic surveys and two before-after studies have examined the relation between steroids and osteoporosis. Although some have shown a strong relation, this finding has not been consistent. Evidence regarding temporality , dose-response gradient, and underlying mechanisms are conflicting. The available evidence does not substantiate a causal role of exogenous adrenocorticosteroids in producing clinically important osteoporosis, and does not support withholding steroid therapy on the basis of fears of osteoporosis induced pain and disability.
mesh_terms: D000305:Adrenal Cortex Hormones / Q000009:adverse effects*; D002986:Clinical Trials as Topic; D004305:Dose-Response Relationship, Drug; D005598:Fractures, Spontaneous / Q000209:etiology; D006801:Humans; D010024:Osteoporosis / Q000139:chemically induced* / Q000150:complications; D011446:Prospective Studies; D012107:Research Design; D013054:Spectrophotometry, Atomic; D013124:Spinal Injuries / Q000209:etiology; D013997:Time Factors
chemical_list: D000305:Adrenal Cortex Hormones