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Corticosteroids as standalone or add-on treatment for sore throat.

What Is This Review About?

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References

The use of corticosteroids to reduce pain in adults and children with sore throat.

What Are the Findings?

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References

For studies involving children and adults with sore throat, a single dose of intramuscular dexamethasone or oral corticosteroids for 1–3 days, as an adjunct to antibiotics and analgesics, increases the likelihood of complete resolution of pain at 24 h by 3.2 times (95% confidence interval (CI) 2.0–5.1) and at 48 h by 1.7 times (95% CI 1.3–2.1). Corticosteroids also reduce the mean time to onset of pain relief and mean time to complete resolution of pain by 6 and 14 h, respectively. When analysed in more detail, the data from studies in children with sore throat are less clear than those for adults. For all studies, there does not appear to be a difference in rates of recurrence, relapse and adverse events in those taking steroids compared with placebo. However, overall the trials were not sufficiently powered and the length of observation was inadequate for accurate assessment of these outcomes.

What Are the Findings Based On?

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References

The review included eight randomised control trials involving 743 participants; 369 were children (>3 years old) and 374 adults. Studies were excluded if they involved patients that were hospitalised, had infectious mononucleosis, had sore throat following tonsillectomy or intubation or had peritonsillar abscess. There was a low risk of bias across all studies.

No trials assessed corticosteroids as stand-alone treatment and only one trial controlled for analgesic use. All trials gave antibiotics to patients in both the intervention and placebo arms. However, there was considerable variability in antibiotic administration between trials: some gave antibiotics to all, some prescribed based on a positive group A streptococcal antigen test and/or culture, and others at the discretion of the treating clinician.

For the three trials that studied children and adolescents (age range 4–21 years, two conducted in the USA and one in Canada), the findings were less robust. One trial (ages 4–21 years, oral dexamethasone 0.6 mg/kg for 1 or 3 days)[1] found that patients treated with corticosteroids were 1.7 times (95% CI 0.8–3.5) and 1.4 times (95% CI 1.0–2.1) more likely to experience complete resolution of pain at 24 and 48 h, respectively. The other two paediatric trials gave a single dose of oral dexamethasone 0.6 mg/kg and used a different measure of efficacy. One of these trials (ages 5–18 years) found that corticosteroids reduced time to onset of pain relief by 9 h (95% CI 4.2–13.8 h) compared with placebo, and reduced time to complete resolution of pain by 13.5 h (95% CI 0.9–26.1 h).[2] These findings were not replicated in the other trial (ages 5–16 years), where the time to onset of pain relief was reduced by only 30 min (95% CI −4.6 to 5.6 h) compared with placebo, and the time to complete resolution of pain was actually greater in the corticosteroid group than the placebo group by 2.3 h (95% CI −13.3 to 8.7 h).[3]

For overall data (adults and children), there was heterogeneity in corticosteroid therapy in terms of type, route (oral or intramuscular) and course duration. Oral corticosteroids were less effective than intramuscular at resolving pain at 24 h, although both were more effective than placebo (oral corticosteroids 2.6 times more likely than placebo to resolve pain, 95% CI 1.5–4.3; intramuscular 4.7 times more likely than placebo, 95% CI 2.1–10.5).

Corticosteroids reduced pain faster in patients with bacterial pharyngitis, compared to those with non-bacterial pharyngitis (mean time to onset of pain relief reduced by 5.3 h, 95% CI 2.6–8.0 h, compared with 3.9 h, 95% CI 1.4–9.2 h), although these findings were not statistically significant. There was a similar trend for those with severe exudative sore throat.

Only one of eight studies reported on adverse events and secondary complications from group A streptococcal infection in detail; in this study of 125 children, 5 (4%) were hospitalised for fluid rehydration and 3 (2.4%) developed peritonsillar abscess (1 corticosteroid and 2 placebo).[2] Overall, there was insufficient information to assess adverse outcomes from corticosteroid use, particularly complications of group A streptococcal infection.

Implications for Practice

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References

A short course of corticosteroids may be used to reduce the pain of a sore throat in adult patients; the data are less clear for children.

Clinical Perspective

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References

In high-income countries, excessive rates of antibiotics are prescribed for sore throat despite the low risk of secondary complications and a high incidence of viral sore throat in these populations. Prescribing antibiotics in this setting is largely to alleviate symptoms, a practice that is controversial, given that high rates of antibiotic prescribing increases bacterial resistance as well as increasing the risk of adverse effects in individuals. An exception to this is in the Indigenous population of Australia and in many low-income countries, where rheumatic fever is common and where antibiotic treatment is clearly indicated.

This review suggests that corticosteroids reduce pain from pharyngitis in adults. The data from the paediatric studies are less convincing. Using corticosteroids to reduce the pain from sore throat could confer benefit beyond that of symptom relief by reducing antibiotic use and reducing time away from school or work, although these effects are yet to be demonstrated. Steroids may also offer a clear alternative to oral and topical analgesics, whose benefit is unclear, filling this therapeutic void. >

As noted, all studies included antibiotic treatment for participants in both arms. Antibiotics reduce the risk of suppurative complications such as peritonsillar abscess (quinsy), although the number needed to treat is large.[4] In theory, using corticosteroids alone could potentially increase the risk of these suppurative complications, particularly in children with bona fide group A streptococcal infection, and in populations excluded from the trials in the review (e.g. hospitalised patients). Worthy future work would be to explore, in settings where the risk of rheumatic fever is low (e.g. non-Indigenous Australians), how corticosteroid treatment compares to placebo or simple analgesia such as non-steroidal anti-inflammatory drugs or paracetamol, in the absence of antibiotic therapy.

Introducing corticosteroids into clinical practice for the management of sore throat in children is premature at this stage. Further studies assessing the role of corticosteroids particularly in children, as well as assessing potential adverse outcomes, are warranted.

References

  1. Top of page
  2. What Is This Review About?
  3. What Are the Findings?
  4. What Are the Findings Based On?
  5. Implications for Practice
  6. Clinical Perspective
  7. References
  • 1
    Niland ML, Bonsu BK, Nuss KE, Goodman DG. A pilot study of 1 versus 3 days of dexamethasone as add-on therapy in children with streptococcal pharyngitis. Pediatr. Infect. Dis. J. 2006; 25: 477481.
  • 2
    Olympia RP, Khine H, Avner JR. Effectiveness of oral dexamethasone in the treatment of moderate to severe pharyngitis in children. Arch. Pediatr. Adolesc. Med. 2005; 159: 278282.
  • 3
    Bulloch B, Kabani A, Tenenbein M. Oral dexamethasone for the treatment of pain in children with acute pharyngitis: a randomized, double-blind, placebo-controlled trial. Ann. Emerg. Med. 2003; 41: 601608.
  • 4
    Spinks A, Glasziou PP, Del Mar CB. Antibiotics for sore throat. Cochrane Database Syst. Rev. 2010; (9): CD000023.