reduce the need for antibiotics. NICE does not ... throat as there are safer alternatives for a self-limiting infection
Medicines Evidence Commentary commentary on important new evidence from Medicines Awareness Weekly
Published: January 2018
Sore throat: corticosteroids as an add on treatment A systematic review and meta-analysis of 8 randomised controlled trials investigated the benefits and harms of using corticosteroids as an adjunct treatment for sore throat. The review found that people using corticosteroids were more likely to be symptom free at 24 and 48 hours compared with people taking a placebo. However, the onset of pain relief was only reduced by 4.8 hours in people using corticosteroids, and corticosteroids did not significantly reduce the need for antibiotics. NICE does not recommend corticosteroids for managing sore throat as there are safer alternatives for a self-limiting infection (sore throat (acute): antimicrobial prescribing).
Overview and current advice Acute sore throat is a self-limiting condition which is usually caused by a viral infection of the upper respiratory tract. Symptoms can last for around 1 week, and most people will get better within this time regardless of whether the sore throat is caused by a bacterial or viral infection. The NICE guideline on sore throat (acute): antimicrobial prescribing, advises that antibiotics are not needed for most people and complications of sore throat are rare. Clinical scoring systems (either FeverPAIN or Centor) can be used to identify people who are more likely to benefit from antibiotics. Corticosteroids, in particular the glucocorticoids, are associated with adverse effects such as diabetes, osteoporosis, avascular necrosis of the femoral head, muscle wasting, peptic ulceration and perforation and psychiatric reactions. Corticosteroids are not recommended by NICE for the treatment of sore throat.
New evidence A systematic review and meta-analysis of 10 randomised control trials (RCTs) by Sadeghirad et al. 2017 investigated the benefits and harms of using corticosteroids as an adjunct treatment for sore throat in 1,426 people (average age range 7.7 to 35.3 years). Eight of the studies were carried out in hospital emergency departments and 2 in primary care. Study participants were randomised to either corticosteroid treatment or standard care (antibiotics and/or analgesia). The authors compared outcomes of pain and antibiotic use in these groups. In 3 studies all participants received antibiotics and analgesics, in 2 studies all participants received antibiotics but analgesics were prescribed at the clinician’s discretion and in 5 of the studies both antibiotics and analgesics were prescribed at the clinician’s discretion. Oral dexamethasone, prescribed as a single dose (maximum dose 10 mg), was the most frequently used corticosteroid, followed by intramuscular dexamethasone (maximum dose 10 mg, single dose), and prednisone
(60 mg, single dose) and betamethasone (8 mg, single dose) were used in 1 trial each. The review reported symptom outcomes, in addition to relapse rates, antibiotic use, days missed from school and adverse events. The review found that, compared with placebo, people using corticosteroids were more likely to be symptom free after 24 hours (relative risk [RR] 2.24; 95% confidence interval [CI] 1.17 to 4.29, 5 RCTs) and 48 hours (1.48; 95% CI 1.26 to 1.75, 4 RCTs). Additionally, the mean time to onset of pain relief was 4.8 hours earlier (95% CI -1.9 to −7.8, 8 RCTs, n=907) and the mean time to complete pain resolution was 11.1 hours earlier (95% CI −0.4 to −21.8, 6 RCTs, n=720) compared with those receiving standard care. The 8 studies that assessed pain at 24 hours on an 11-point visual analogue scale showed an absolute reduction in pain score of 1.3 points in those treated with corticosteroids compared with those receiving placebo. In one of the studies conducted in UK primary care, there was no difference in symptom resolution at 24 hours (primary end point) but there was a statistically significant difference in symptoms at 48 hours (RR 1.31, 95% CI 1.02 to 1.68). This was the only study that investigated antibiotic use after treatment with corticosteroids, finding no significant difference between those receiving corticosteroids and those receiving placebo (RR 0.83, 95% CI 0.61 to 1.13). The isolation of Streptococcus in this study was 14.9% which is more representative of the UK population presenting in primary care than other studies in this systematic review (mean 51.38%, range 14.9 to 100%).
Commentary Commentary provided by NICE This systematic review and meta-analysis of 10 RCTs involving 1,426 adults and children found a single dose of corticosteroids increased the likelihood of being symptom-free at 24 and 48 hours. Almost 40% of participants came from a single RCT (Hayward et al. 2017). The authors suggest that using corticosteroids could reduce the need for antibiotic prescribing, although this conclusion should be considered with caution. Only 1 study (Hayward et al. 2017, n=565) reported the effect on antibiotic usage, finding no significant difference in antibiotic prescribing between those prescribed corticosteroids and those who were given placebo. This study also investigated the role of corticosteroids in the absence of an antibiotic prescription, but this meant that those with a more severe sore throat requiring immediate antibiotics were excluded. In this study no significant improvement in pain outcomes was found in those prescribed dexamethasone. The authors suggested that this could be due to a synergistic effect of corticosteroids and antibiotics occurring in other studies where they were given in combination. There was no difference in adverse events between people using corticosteroids and those receiving standard care. It is possible that adverse events from corticosteroid use may be more prevalent in people with comorbidities; these populations were excluded and the RCTs were not powered to detect rare adverse events associated with corticosteroids. Also, the studies investigated single doses of corticosteroids only, so it is likely that in practice some people could receive repeated doses for recurrent sore throats and this increased steroid use may lead to a higher risk of side effects. Of the 2 studies which were conducted in primary care, 1 showed a significant improvement in symptom resolution at 24 hours but the authors only included participants with severe sore throat presenting at general practice in Israel. In this study there were differences between the number of participants who tested positive for Streptococcus, with 51% in the prednisone arm and 63% in the placebo arm. This difference could influence the course of infection and could explain the difference seen in outcomes at 24 hours. Additionally, such a high isolation of Streptococcus (average 58%) in people with sore throat is not representative of the UK primary care population, where rates are typically much lower (around 20%).
This systematic review demonstrated that corticosteroids could provide pain relief in sore throat at 24 and 48 hours, however there was no evidence of effect on antibiotic prescribing. There was no reported difference in side effects, although it was not possible to determine the risks of repeated doses for people with recurrent sore throat. Sore throat severity should be assessed as recommended in the NICE guideline on sore throat (acute): antimicrobial prescribing before considering antibiotics or corticosteroids.
Study sponsorship None reported.
References Sadeghirad B, Siemieniuk R, Brignardello-Petersen R et al. (2017) Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials Hayward N, Hay A, Moore M et al. (2017) Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults
About this Medicines Evidence Commentary Medicines Evidence Commentaries form part of NICE’s Medicines Awareness Service and help contextualise important new evidence, highlighting areas that could signal a change in clinical practice. They do not constitute formal NICE guidance. The opinions of contributors do not necessarily reflect the views of NICE.
Visit Evidence Search Copyright © NICE 2018. All rights reserved. Subject to Notice of rights.
