Corticosteroids for Sore Throat: BMJ Rapid Recommendation

Acute sore throat typically resolves after seven to 10 days in adults and two to seven days in children. It can result in missed school or work, but complications are rare. Most guidelines recommend acetaminophen or ibuprofen as a first-line treatment and discourage the use of corticosteroids. However, a large randomized controlled trial found that corticosteroids increased the likelihood of symptom resolution at 48 hours. Based on this study, the BMJ Rapid Recommendations team, a collaboration between BMJ and the MAGIC group, issued a weak recommendation to give a single dose of oral corticosteroids to most patients with acute sore throat.

The recommendation applies to patients at least five years of age with severe or nonsevere sore throat of viral or bacterial etiology who were prescribed immediate or deferred antibiotics. It does not apply to immunocompromised patients or those with infectious mononucleosis, recurrent sore throat, or sore throat after surgery or intubation.

Although corticosteroids are effective for the treatment of sore throat, they do not considerably reduce the severity or duration of pain or improve other patient-oriented outcomes (e.g., time off from work or school, risk of relapse). For this reason, the recommendation to use corticosteroids is weak, and the decision to use these medications should be made jointly between the physician and patient.

The panel identified eight outcomes needed to inform the recommendation: complete resolution of pain, time to onset of pain relief, pain severity, need for antibiotics, days missed from school or work, recurrence of symptoms, duration of bad or intolerable symptoms, and adverse effects. It determined that corticosteroids increase the likelihood of complete resolution of pain at 24 and 48 hours, reduce the severity of pain, and shorten the time to onset of pain relief (high- to moderate-quality evidence). However, corticosteroids are unlikely to reduce recurrence or relapse of symptoms or days missed from school or work (moderate-quality evidence). A single dose of corticosteroids is not likely to cause serious adverse effects (moderate-quality evidence). The panel was less confident about whether corticosteroids reduced antibiotic use or the average time to complete resolution of pain (low-quality evidence).

Corticosteroids are typically given as 10 mg of dexamethasone for adults (0.6 mg per kg for children, up to a maximum dose of 10 mg), taken as pill or intramuscular injection, but equivalent doses of other corticosteroids may be used. The risks may outweigh the benefits when larger doses are given to patients with multiple episodes of sore throat. To mitigate this issue, clinicians should administer the medication in the office, if possible, or prescribe only one dose per visit.

Editor's Note: The role of shared decision making cannot be overemphasized. A single dose of corticosteroids may seem harmless, but this may not be the case for cumulative use. We have to ask ourselves and our patients how much they will benefit if there are no fewer days missed from school or work. A corticosteroid conversion calculator is available at https://www.mdcalc.com/steroid-conversion-calculator.

Evidence rating system used? Yes

Systematic literature search described? Yes

Guideline developed by participants without relevant financial ties to industry? Yes

Recommendations based on patient-oriented outcomes? Yes

Published source:BMJ. 2017;358:j4090