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