Corticosteroids in Pharyngitis – Systematic Review + Meta-Analysis

Background: Sore throat is among the most common complaints in the emergency department (ED). Sometimes, the etiology is bacterial, and in those cases antibiotics may shorten the duration of disease and provide symptomatic relief. The majority of cases are viral and though most are appropriately treated with symptom management in the forms of NSAIDS and acetaminophen, some are prescribed antibiotics before cultures result in the hopes of alleviating pain. Corticosteroids are another treatment modality with prior studies suggesting their effectiveness. That said, steroids remain an uncommon therapy for a common disease.

Article: Sadeghirad B et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials BMJ 2017; 358 :j3887. PMID: 28931508

Clinical Question:

Do single, low dose corticosteroids provide symptomatic relief in undifferentiated pharyngitis without significant adverse effects?

Design: Systematic review and meta-analysis of randomized control trials

Population: Patients aged 5 and over in the ED and primary care settings with a clinical syndrome of sore throat (painful throat, odynophagia, or pharyngitis).

Excluded: Excluded studies of patients admitted to the hospital, immunocompromised patients, patients with mononucleosis, post surgical and post intubation sore throat, GERD, croup, PTA

Intervention: Standard of care (abx if indicated +/- analgesia) + corticosteroids

Control: Standard of care (abx if indicated +/- analgesia)

Outcomes:

Complete resolution of pain at 24 and 48 hours

Mean time to onset of pain relief

Mean time to complete resolution of pain

Absolute reduction of pain at 24 hours

Recurrence or relapse of symptoms

Days missed from school or work

Need for antibiotics

Rate of adverse events related to treatment

Results:

10 RCTs that studied a total of 1426 individuals

One RCT in this meta analysis reported a possible decrease in antibiotic use among those receiving steroids

Two studies showed a possible decrease in amount of work missed among those receiving steroids

No significant adverse events reported

Critical Results:

At 24 hours, patients who received single dose steroids were twice as likely to experience symptom resolution when compared to placebo 22.4% vs. 10% (RR 2.24, 95% CI 1.17 to 4.29) NNT = 8

At 48 hours, patient who received steroids were 50% more likely to experience symptom resolution when compared to placebo 60.8% vs. 42.5% (RR 1.48, 95% CI 1.26 to 1.75) NNT = 5.5

Mean time to onset of pain relief was 4.8 hours earlier in patients who received steroids

Mean time to complete resolution of symptoms was 11.1 hours earlier in patient who received steroids

Absolute reduction of pain at 24 hours was 1.3 points lower (3.3 vs 4.6 on a scale of 0 – 10) in patients who received steroids (95% CI 0.7 to 1.9)

Subgroup of patients given IM steroids had slightly better outcomes in comparison to oral steroids

Strengths:

Looked at an important clinical and patient centered outcome

Searched for articles in multiple databases (Medline, Embase, Cochrane)

Studies included were evaluated for quality of evidence using a GRADE approach and risk of bias using the Cochrane risk of bias instrument

Meta analysis reviewed only randomized control studies

Thorough exclusion criteria to avoid confounding elements such as EBV and PTA

Included most prior, relevant RCTs on the matter and included the latest published in 2017 examining pharyngitis without initial antibiotic administration

Limitations:

Two out of ten studies did not include any data on adverse events

“Standard care” was not standardized across studies – some patients got analgesics, some did not; some patients got antibiotics, some did not

Heterogeneity between studies was moderate

Many of these studies included patients with mild symptoms. There may have been a larger benefit in patients with more severe disease

The dose of steroids in pediatric patients (i.e. dexamethasone 0.6 mg/kg) may not truly be “low dose.” An 18-kg child would get 10 mg of dexamethasone as would an adult

Imprecise and inconsistent data behind many of the outcome results

Studies used different steroid treatments. Most studies used single low dose dexamethasone as their intervention. One study provided more than one dose, one study used prednisone, one study used betamethasone.

Author’s Conclusions:

“Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects.”

Our Conclusions:

Of all the outcomes, only the complete resolution of symptoms at 48 hours is backed by high quality evidence and a narrow confidence interval. Steroids also appear to provide only a moderate improvement in time to and degree of resolution of symptoms. However, in the setting of severe symptoms, these moderate improvements could make a significant difference.

Potential to Impact Current Practice:

This study validates prior studies suggesting corticosteroids offer therapeutic benefit in the management of sore throat. Clinicians should strongly consider adding a single dose of corticosteroids to their treatment regimen for patients with pharyngitis.

Bottom Line:

In cases of severe pharyngitis, single low dose corticosteroid administration would likely provide symptomatic benefit that outweigh potential adverse effects.

Guest Post By:

Allon Mordel, MD

PGY4 Resident

NYU/Bellevue Emergency Medicine Department

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Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)