In patients with acute sore throat, there is primarily moderate to high quality evidence that one or two low doses of corticosteroids reduces the intensity and duration of pain—pain scores at 24 hours, complete resolution of pain at 24 and at 48 hours, time to onset of pain relief, and time to complete pain relief. In this review, results were consistent across studies and across all pain outcomes (table 2⇑). The reduction in pain achieved was modest—for example, mean time to complete resolution of pain was about 11 hours shorter, and about 18% more patients had complete pain relief at 48 hours. At 24 hours, the mean improvement in pain scores was about 13 mm on a visual analogue scale from 0 to 100 mm (with the minimal important difference being about 10 mm).32 The relative effects were similar across severities, though patients with less severe sore throat had less absolute benefit from corticosteroids. The balance of benefits and harms therefore almost certainly depends on the severity of the patient’s sore throat.

Whether corticosteroids reduce recurrence/relapse of symptoms, number of days missed from school or work, duration of bad/intolerable symptoms, or antibiotic use remains uncertain. Regarding the safety of the short courses and low doses of corticosteroids, studies reported few adverse effects, with no apparent increase in events in patients treated with corticosteroid.

Strengths and limitations of study

Strengths of this review include explicit eligibility criteria; a comprehensive search developed with a research librarian; duplicate assessment of eligibility, risk of bias, and data abstraction; consideration of all outcomes important to patients; consideration of selective reporting bias; consideration of possible subgroup effects; and rigorous use of the GRADE approach to rate quality of evidence. The limitations of our review have to do with the underlying evidence. Only three trials explicitly reported adverse events, and they did so inconsistently.162528 We observed substantial statistical heterogeneity in some of the outcomes. We explored the source(s) of heterogeneity by subgroup analysis and rated down for inconsistency in GRADE assessments for outcomes with unexplained heterogeneity.

In comparison with previous systematic reviews,1112 we included two additional randomised controlled trials,1626 which almost doubled the number of participants. Results from our meta-analysis are consistent with previous findings that corticosteroids reduce pain at 48 hours and probably reduce other pain outcomes. In addition to enhanced precision with the additional studies, our meta-analysis adds to the existing evidence in that we considered absolute in addition to relative effect measures, providing a clear picture of the magnitude of effect.33 In part because of input from the guideline panel, we considered additional outcomes that participating patients considered important, including risk of recurrence of symptoms, duration of bad/non-tolerable symptoms, need for antibiotics, and days missed from school or work. An important additional contribution of the new evidence is that it extends the applicability beyond patients with severe sore throat treated with antibiotics for group A β haemolytic streptococcus pharyngitis in the emergency department, to a broader range of patients not treated with antibiotics.

We explored and were able to dismiss subgroup effects, with one exception: the reduction in mean time to complete resolution of pain was greater with intramuscular than with oral corticosteroids. The subgroup effect and its direction was specified a priori, the difference between subgroups was relatively large (about 21 hours), and chance seems an unlikely explanation (P<0.001). Credibility of the effect, however, is undermined34 as the effect modification is suggested by comparison between rather than within studies, and we found no similar difference in any other outcome. In addition, the only randomised controlled trial that compared oral and intramuscular treatment with dexamethasone reported no significant difference in any outcome.25

The few serious adverse effects in the included trials occurred with similar frequency in the intervention and control groups, although some minor adverse effects reported by patients might not always have been noted. Potential adverse effects that appear later are more likely to occur after repeated use or are rare would not have been captured in the trials. Recent observational studies have raised the possibility of extremely rare but serious adverse effects after short courses of corticosteroids.35 The quality of this evidence is, for several reasons, low with respect to the current question. The studies used observational designs from large databases with suboptimal verification of diagnoses; serious confounding by indication raises the possibility that the association is a result of the underlying disease process (such as acute inflammation or exacerbation) rather than the corticosteroids themselves; and indirectness in that the doses used in the trials were lower and the duration of treatment was considerably shorter than the duration in the observational studies. Among children, a recent overview of reviews looked at evidence from 44 randomised controlled trials on conditions that required a short course of steroids (such as asthma, bronchiolitis, croup, wheeze, and pharyngitis/tonsillitis) and reported no major adverse events.36

Despite previous evidence that corticosteroids might be beneficial, several groups and guidelines currently recommend against their routine use on the basis that evidence was applicable only to patients with severe pharyngitis who were also prescribed antibiotics in an emergency department.13738 The body of evidence now includes a broader representation of patients. The largest and most recent randomised controlled trial included 565 patients presenting to their general practitioner rather than an emergency department, and none of the patients initially received antibiotics.16 We found no subgroup differences with respect to patient group: the evidence seems to apply equally to patients who did and did not receive antibiotics. The evidence also seems to apply equally to patients with sore throat from group A β haemolytic streptococcus pharyngitis and some with sore throat negative for group A β haemolytic streptococcus.

In the five trials that reported co-interventions, about 80% of the participants received additional analgesics such as paracetamol and NSAIDs. Therefore, a single dose of corticosteroids seems to further reduce pain when used in combination with other analgesics. Although the benefits are relatively small, many patients are likely to consider them important. Patients with less severe sore throat, however, will obtain less absolute benefit from corticosteroids. Thus, the balance of benefits and harms almost certainly depends on the severity of the patient’s sore throat. With available evidence suggesting that serious adverse effects are rare or absent, the addition of one or two doses of steroids to the symptomatic management of sore throat is likely to appeal to many patients. More high quality data would be helpful to fully understand the net balance of benefits and harms according to severity of symptoms, particularly in primary care settings.

Linked articles in this BMJ Rapid Recommendations cluster • Aertgeerts B, Agoritsas T, Siemieniuk RAC, et al. Corticosteroids for sore throat: a clinical practice guideline. BMJ 2017;358:j4090 doi:10.1136/bmj.j4090 summary of the results from the Rapid Recommendation process

Magic App (www.magicapp.org) expanded version of the results with multilayered recommendations, evidence summaries, and decision aids for use on all devices

