Clinical Scenario: A 22-year-old man with a history of poorly controlled diabetes presents with 3 days of sore throat. Vitals are HR 82, BP 120/73, RR 16, Temp 98.8, O2 sat 99% on RA. He endorses cough and nasal congestion but no fevers. His primary symptoms are sore throat and odynophagia He has tried over-the-counter NSAIDs with only minor improvement in symptoms.
Exam reveals a non-toxic patient with moist mucous membranes. His oropharyngeal exam reveals erythema without swelling of the tonsils or any tonsillar exudate. There is no trismus and no anterior neck tenderness to palpation. BGL = 288g/dL and there are no ketones in the urinalysis. Given failure of NSAIDs, you contemplate administering a dose of corticosteroid to the patient prior to discharge home.
What Your Gut Says: Easy call. Just give the steroids. There is a clear benefit to patients in terms of pain relief and symptom resolution.
What The Evidence Says:
Sore throat is among the most common complaints in the emergency department (ED). Sometimes, the etiology is bacterial, and in those cases antibiotics may be indicated (we won’t address the role of antibiotics in strep throat but check out this post for more). Although the majority of cases are viral and the symptoms can be managed by NSAIDS and acetaminophen, this treatment approach is occasionally inadequate. The use of corticosteroids is a treatment modality that has gained traction in recent years due to perceived significant benefit without significant harms.
This treatment shift arises from numerous high-quality studies culminating with a Cochrane Database review published in 2012 (and updated in 2020) and a well-done meta-analysis published in the BMJ in 2017. The BMJ analysis concluded that, “Single low-dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects.” (Sadeghirad 2017) The Cochrane Database conclusions echo this statement, “Oral or intramuscular corticosteroids, in addition to antibiotics, moderately increased the likelihood of both resolution and improvement of pain in participants with sore throat.” (de Cassan 2020).
| Number of Studies | Number of Patients (children) | Relative Risk/Risk Ratio for Pain Reduction* | |
| BMJ 2017 | 10 | 1426 (394) | 2.2 (CI 1.2-4.3) |
| Cochrane 2020 | 9 | 1319 (369) | 2.4 (CI 1.29 – 4.47) |
*The relative risk/risk ratio for benefit reflects the probability of the outcome (improvement in pain) in the treatment arm compared to the non-treatment arm.
There are some important considerations that affect management in these conclusions. Most importantly, immunocompromised patients were excluded from all of the reviewed studies. There is little specification as to what “immunocompromised” includes and this will be left to the discretion of the treating physician. In addition to patients with AIDS, advanced cancer and those on immunomodulators – poorly controlled diabetes should also be considered as steroids are known to raise blood sugar levels.
Both studies included RCTs with adults and children > 5 years of age. Significant numbers of pediatric patients were enrolled in contributing studies making the recommendations applicable in the pediatric group. Numerous single dose preparations of corticosteroids were used both in terms of dose and route. The most common interventions were dexamethasone 0.6 mg/kg (max dose 10 mg) PO/IM and prednisone 60 mg PO. There was no suggestion in the data that route or specific corticosteroid makes a difference in benefit. Both groups report the absence of any significant adverse events but the Cochrane review notes overall poor reporting of adverse events making conclusions difficult. While the Cochrane group concluded that steroids were beneficial when added to antibiotics, there are studies looking at steroids alone with similar benefits (Hayward 2017). Of note, steroids can be paired with both acetaminophen and NSAIDs.
Bottom Line: A single dose of corticosteroids appears both safe and efficacious in the treatment of adult and pediatric (> 5 years old) patients with acute pharyngitis. theNNT.com gives this recommendation a ‘number needed to treat’ of 3 (for every 3 patients treated, 1 will have a significant reduction in pain at 48 hours). However, careful consideration should be taken in immunocompromised patients and children < 5 years old as these patients were not studied.
Read More
- REBEL EM: Corticosteroids in Pharyngitis – Systematic Review and Meta-Analysis
- REBEL EM: The TOAST Trial – Dexamethasone for Acute Pharyngitis
- The NNT: Corticosteroids for Acute Pharyngitis
References
- Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508
- de Cassan S et al. Corticosteroid as standalone or add-on treatment for sore throat (Review). Cochrane Database of Systematic Reviews 2020. PMID: 32356360
- Hayward GN et al. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA 2017; 317(15): 1535 – 1543. PMID: 28418482
Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter/X: @srrezaie)
