Steroids as Adjuvant Therapy for Acute Pharyngitis in Ambulatory Patients: A Systematic Review

Katrin Korb, MD; Martin Scherer, MD, PhD; Jean-François Chenot, MD, MPH

Ann Fam Med. 2010;8(1):58-63.

Abstract and Introduction

Abstract

Purpose This review summarizes the evidence regarding the efficacy of adjuvant steroids for pain reduction in acute pharyngitis.
Methods We searched for randomized controlled trials, using MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews, published between 1966 and December 2008. Two reviewers assessed the quality of each retrieved article and summarized the data.
Results Our review found 8 relevant randomized controlled trials (RCTs) with a total of 806 patients. There were 5 RCTs with adult patients and 3 with children. All RCTs found a statistically significant faster reduction of pain or complete pain relief from steroid use compared with placebo. The trials used different steroids (dexamethasone, betamethasone, prednisone), and most participants had received antibiotics at least initially. Analgesic medication, such as acetaminophen, was allowed in all studies, but this factor was not always controlled. No serious adverse side effects were reported.
Conclusions Steroids are effective in relieving pain in acute pharyngitis. Although no serious adverse effects were observed, the benefits have to be balanced with possible adverse drug effects. There are safe and effective over-the-counter medications to relieve throat pain. Most patients received concomitant antibiotics; however, reducing the prescription of antibiotics for generally benign upper respiratory tract infection is a public health goal. We therefore recommend further studies to establish both the safety of steroids without antibiotic coverage and the additional benefits of steroids when used with regular administration of over-the-counter analgesic medications.

Introduction

Sore throat is a highly common condition. In a Scottish survey 31% of respondents reported at least 1 episode of sore throat within the last 12 months; most did not seek medical attention.^[1] Physicians frequently assume that patients seeking care expect a course of antibiotics. It has been shown, however, that pain relief is more important for patients, and patients who hope for antibiotics may in fact want treatment for pain.^[2] Thus, a major treatment goal for patients complaining of sore throat is to relieve pain and alleviate difficulties in swallowing.

Viral or bacterial infections that cause a sore throat generate pain through inflammation of the pharynx and the surrounding lymphatic tissue. Although antibiotic treatment may shorten the duration of symptoms in a bacterial throat infection (from 3.3 to 2.7 days), the benefits are considered moderate.^[3] Gargling, drinking warm liquids, and oral antipyretic or analgesic drugs are common supportive treatments available over the counter.^[4] The anti-inflammatory action of steroids might be effective to relieve symptoms caused by inflammation and has been studied in other upper respiratory tract infections. Steroids might, therefore, represent a useful clinical option to meet patients' needs. Administering intramuscular or oral steroids for acute pharyngitis is not common practice; however, several randomized controlled trials, mainly from the United States and few other countries (Israel, Turkey), have studied the effectiveness of steroids.

We performed a systematic review of the effects of steroids as adjuvant therapy for acute pharyngitis in ambulatory patients and discuss the implications for practice.

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Abstract and Introduction
Methods
Results
Discussion
References

Table 1. Characteristics of the Included Randomized Controlled Trials in Adults
Study, Year, Country	Setting (n)	Mean Age, y	Intervention^a	Co-Intervention	Bacteriology	Main Outcomes	Main Results	Authors' Conclusions
O'Brien et al,^[9] 1993, USA	Educational (51)	26.4	0 mg dexamethasone IM	Antibiotic: yes Analgesic: permitted, controlled	None	15-cm VAS (0–3.0) pain score at 24 h Time until onset of pain relief Time to complete pain relief	6.1-h earlier onset of pain relief (6.3 h vs 12.4 h; P =.01) 20.4-h earlier pain free (15 h vs 35.4 h; P = .02) in the steroid arm	"IM dexamethasone appears effective as an adjuvant to antibiotic therapy"
Marvez-Valls et al,^[7] 1998, USA	Educational (92)	29.2	12 mg beta-methasone IM	Antibiotic: yes Analgesic: permitted, not controlled	In 77 of 92 patients done	10-cm VAS pain score at 24 h and 48 h Change in pain score at 24 h and 48 h Time until onset of pain relief Time to complete pain relief	5-h earlier onset of pain relief (6.3 h vs 11.3 h; P =.005), 13.8-h earlier pain free (42.0 h vs 55.8 h; P = .013) in the steroid arm If GABHS positive: 28.2-h earlier pain free (28.8 h vs 57.0 h; P =.024) in the steroid arm	"As an adjunct to antibiotic therapy, betamethasone appears to lessen time to relief of pain…most effective in streptococcal-positive pharyngitis"
Wei et al,^[8] 2002, USA	Educational (118)	28.1	10 mg dexamethasone IM/oral	Antibiotic: yes Analgesic: permitted, controlled	Yes	Change in 10-cm VAS pain score after 12 h and 24 h Time until onset of pain relief Time to complete pain relief	4-h earlier onset of pain relief (5.8 h IM/6 h oral vs 10.1 h placebo; P = .029) in the steroid arm	"Dexamethasone at a 10-mg …, significantly contributes to relief of pain"
Kiderman et al,^[6] 2005, Israel	General practice (79)	33.9	60 mg prednisone oral 1 or 2 d	Antibiotic: yes Analgesic: permitted, controlled	In 73 of 79 patients done	10-cm VAS pain score at 12 h, 24 h, 48 h, 72 h	Pain reduction at 12 h (3.9 vs 5.9 P <.001) and 24 h (2.4 vs 4.5; P = .002) in the steroid arm	"…adjuvant oral steroid therapy appears to be safe and more effective than placebo for symptom relief"
Tasar et al,^[10] 2008, Turkey	Educational (73)	31.3	8 mg dexamethasone IM	Antibiotic: yes Analgesic: permitted, not controlled	None	Time until onset of pain relief Time to complete pain relief	11.8-h earlier onset of pain relief (8.1 h vs 19.9 h; P <.001) 24.8-h earlier pain free (28.9 h vs 53.7 h; P <.001) in the steroid arm	"Single dose…dexamethasone therapy added to the standard treatment has a more rapid improvement of pain"

Exp = experimental; GABHS = group A β-hemolytic streptococci, IM = intramuscular; VAS = visual analogue scale.
^a All control groups received placebo.

Table 2. Characteristics of the Included Randomized Controlled Trials in Children
Study, Year, Country	Setting (n)	Mean Age, y	Intervention^a	Co-Intervention	Bacteriology	Main Outcomes	Main Results	Authors' Conclusions
Bulloch et al,^[11] 2003, USA	Educational (184)	9.7	10 mg dexamethasone oral	Antibiotic: yes if rapid antigen test positive for GABHS Analgesic: permitted, not controlled	Yes	10-cm VAS pain score at 24 h Change in pain score at 24 h Time until onset of pain relief Time to complete pain relief	If GABHS positive: 5.5 h earlier onset of pain relief (6.0 h vs 11.5 h; P = .02) in the steroid arm	"…oral dexamethasone does not decrease the time to onset of clinically significant pain relief or the time to complete pain relief"
Olympia et al,^[12] 2005, USA	Educational (125)	11.4	Maximum 10 mg dexamethasone (0.6 mg/kg) oral	Antibiotic: yes if rapid antigen test positive for GABHS Analgesic: permitted,	Yes	Change in McGrath Facial Affective scale pain score at 24 h and 48 h Time until onset of pain relief Time to complete pain relief	If GABHS positive: 5.1 h (95% CI, 0.5–10.8 h) earlier onset of pain relief (9.7 h vs 14.8 h) in the steroid arm	"Immunocompetent children with moderate to severe pharyngitis benefited from the use of oral dexamethasone"
Niland et al,^[13] 2006, USA	Educational (84)	8^b	Maximum 10 mg dexamethasone (0.6 mg/kg) oral, 1 or 3 d	Antibiotic: yes Analgesic: permitted, controlled	Yes	Time until onset of pain relief Time improvement of general condition Time to improvement of activity level in days	1 d earlier onset of pain relief (1 d vs 2 d) in the steroid arm	"…children with acute uncomplicated GABHS pharyngitis who receive steroids as add-on treatment are likely to convalesce faster"

CI = confidence interval; Exp = experimental; GABHS = group A β-hemolytic streptococci, VAS = visual analogue scale.
^a All control groups received placebo.
^b Median age.

Table 3. Quality Assessment of Included Trials
Study, Year, Country	Randomization Adequate	Primary Outcome Defined	Dropouts Described	Point Estimates/Measures of Variability	Intention-to-Treat	Power Calculation Described	Double-Blinding	Eligibility Criteria Predefined
O'Brien et al,^[9] 1993, USA	Yes	Unclear	Yes	Yes	No	No	Yes	Yes
Marvez-Valls et al,^[7] 1998, USA	Yes	Yes	Yes (no drop-outs)	Yes	No	Yes	Yes	Yes
Wei et al, 2002,^[8] USA	Unclear	Unclear	Yes	Yes	No	No	Yes	Yes
Kidermann et al,^[6] 2005, Israel	Yes	Yes	Yes (no drop-outs)	Yes	No	Yes	Yes	Yes
Tasar et al,^[10] 2008, Turkey	Yes	No	Yes (no drop-outs)	Yes	No	No	Yes	Yes
Bulloch et al,^[11] 2003, USA	Yes	No	Yes	Yes	No	Yes	Yes	Yes
Olympia et al,^[12] 2005, USA	Yes	Yes	Yes	Yes	No	Yes	Yes	Yes
Niland et al,^[13] 2006, USA	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

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