Corticosteroids for Acute Pharyngitis
Benefits in NNT
1 in 3 were helped (pain improvement within 48 hours)
None were helped (decreased recurrence)
30% were helped by pain reduction at 48 hours
None were helped by decreased recurrence
Harms in NNT
None were harmed (medication side effects)
None were harmed by medication side effects
SourceHayward G, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012 Oct 17;10:CD008268. PMID: 23076943.
Efficacy EndpointsPrimary Endpoints: resolution of pain within 24 hours; resolution of pain within 48 hours; mean time to pain relief, mean time to resolution of pain Secondary Endpoints: recurrence/relapse rate
Harm EndpointsOverall adverse events
NarrativeSore throat is the primary complaint in roughly 12 million emergency room and primary care visits in the US annually.1 Traditionally, symptomatic treatment often involves over-the-counter analgesics. Corticosteroids may provide additional benefit in reducing pain and other symptoms by inhibiting pharyngeal inflammation.4
The Cochrane review summarized here explored the efficacy and safety of steroid use in patients presenting with sore throat, defined as acute tonsillitis, pharyngitis, odynophagia or painful throat. The authors identified eight randomized controlled trials comparing antibiotics with and without corticosteroids. Overall, 743 subjects were analyzed, including 369 children and 374 adults. Of these, 330 (44%) were GABHS positive. Most trials found that steroids (prednisone 60 mg, dexamethasone up to 10 mg, or betamethasone 8 mg) shortened length of symptoms compared to placebo. Patients who received steroids had an increased likelihood of complete symptom resolution at 24 hours (39% vs. 12%), an effect that persisted at 48 hours (77% vs. 47% at 48 hours). Moreover, the addition of steroids shortened average time to pain relief by six hours and complete resolution by 14 hours.
Three studies looked at rate of recurrence and three looked at relapse, finding no statistically significant difference, while one study assessed adverse events and also found no difference.
CaveatsThe trials included here are, in aggregate, relatively small, and compared different corticosteroids, given at different doses, using different routes of administration. Most of the trials used a single dose of dexamethasone, and in the trials that compared routes, there was no significant difference in symptoms between oral and intramuscular injection. In addition, seven of eight trials allowed but did not control for other analgesics. Antibiotics were co-administered with and without steroids, and no studies assessed the efficacy of steroids in the absence of antibiotics. As the majority of pharyngitis cases are viral in etiology and do not benefit significantly from antibiotics5, studies assessing the efficacy of steroids in the absence of antibiotics would be useful.
Finally, steroids in general are well tolerated, particularly with short term use, but there are known adverse effects such as hyperglycemia and mood changes.6 While no harms were identified in this analysis, and although they may be rare, the trials included here were underpowered to detect adverse events.
Only two of the included studies focused on pediatric patients, and together yielded mixed results. In addition, there are reported cases in which steroids have masked acute leukemia in pediatric patients presenting with sore throat.7 Thus, further study in children is warranted.
AuthorJonathan Fu, MD and Gary Green, MD
Published/UpdatedJanuary 25, 2015
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Snow V, Mottur-Pilson C, Cooper RJ, et al. Principles of appropriate antibiotic use for acute pharyngitis in adults.Ann Intern Med 2001; 134:506.
Welch JL and Cooper DD. Do corticosteroids benefit patients with sore throat? Ann Emerg Med. 2014 Jun;63(6):711-2.
Saag KG and Furst DE. Major side effects of systemic glucocorticoids. Uptodate, Waltham, MA (Accessed on December 18, 2014).