Published 6 August 2009, doi:10.1136/bmj.b2476
Cite this as: BMJ 2009;339:b2476

Editorials

Sore throat in primary care

Steroids reduce pain in the first day, but data on harms are lacking

In the linked study (doi:10.1136/bmj.b2976), Hayward and colleagues report a useful and well performed systematic review in a highly topical area.¹ Clinicians and patients need information about interventions other than antibiotics for sore throat for several reasons—the benefit of antibiotics for most patients is modest^{2 3}; the use of antibiotics should be minimised because of the danger of resistance^{3 4}; and other effective treatments, apart from the use of analgesics, anti-inflammatory drugs,⁵ and possibly Echinacea, are lacking.⁶ This systematic review provides evidence that in the first 24 hours steroids may help resolve pain (the likelihood of resolution was increased threefold, number needed to treat (NNT) 3.7) and reduce the mean time to onset of pain relief by six hours. Furthermore, given that most patients in the included studies had antibiotics, although the effect of antibiotics is modest, the effect of steroids in those not receiving antibiotics may be larger.

However, clinicians should be aware of several problems with the sample and intervention when applying the data from the review to their patients. Although meta-regression analysis showed no significant differences across all subgroups, the power of meta-regression to detect an interaction of treatment effects and subgroups is limited, and the estimates in key subgroups provide pause for thought. Firstly, in terms of relevance to practice, most of these studies were unusual in having a high proportion of people with a confirmed bacterial sore throat or with tonsillar exudate, and in studies where less than 50% of patients had exudate the effectiveness of the intervention was estimated to be 45% lower. Patients with bacterial infection and exudate are likely to present more rapidly with an acute illness, but also to settle more rapidly,⁷ which should be borne in mind when considering the natural course of the disease. Secondly, in terms of the intervention, although both oral and intramuscular steroids worked, the effect of oral steroids was estimated to be 30% lower. Thus steroids might have a considerably smaller effect in a typical primary care population, where most patients do not have exudate and will probably be given oral steroids (if given anything).

The other key concern is the complications of steroids, which cannot be investigated in a meta-analysis of this size. Few quality data are available from observational datasets on complications caused by immune suppression and rarities such as aseptic necrosis of the femoral hip.⁸ Reassuringly, for a range of conditions mostly managed in secondary care where infection is implicated—from bacterial meningitis and sepsis to the management of asthma—steroids seem to help resolve the illness and may limit complications,^{9 10 11 12} perhaps because they minimise the adverse effect of a severe inflammatory response. The size of these reviews is too small to assess rare complications, however, and whether the balance of benefits and harms applies in typical primary care populations is unclear.

The final question is the clinical importance to patients of the benefit shown. The apparently impressive benefit in the first 24 hours—particularly a low NNT—requires careful interpretation. In the group of more severely affected patients included in this review, pain settled rapidly in the first 24 hours in the placebo group (from around 7-9 out of 10 on the visual analogue scale to around 3-4). Thus because pain is settling rapidly, steroids that aid resolution in the first 24 hours by around six hours prevent people from having mild pain which is settling rapidly. Clinicians also need to be careful about applying NNTs for an illness that settles rapidly—it is easy to assume when deciding on treatment that the NNT refers to preventing symptoms of the order of severity seen at presentation, but in such cases it is preventing less severe symptoms further on in the natural course of disease.

Clearly more research is needed, particularly more robust evidence for the use of oral steroids in more typical populations and in patients not receiving antibiotics; better data are also needed about the likely incidence of rare complications in primary care. In the meantime, what should clinicians advise their patients given these uncertainties? Clinicians should outline the evidence for the efficacy of steroids in terms of pain control during the first 24 hours (in terms of how rapidly the placebo groups settle and the additional benefit from steroids), convey the slight uncertainty about rare side effects, and then let the patient decide.

Cite this as: BMJ 2009;339:b2476

¹ University of Southampton, Southampton SO16 5ST

Research, doi:10.1136/bmj.b2976

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Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Hayward G, Thompson M, Heneghan C, Perera R, Del Mar C, Glasziou P. Corticosteroids for pain relief in sore throat: systematic review and meta-analysis. BMJ 2009;339:b2976.[Abstract/Free Full Text]
2. Del Mar C, Glaziou P, Spinks A. Antibiotics for sore throat. Cochrane Database Syst Rev 2006;(4):CD000023.
3. National Institute for Health and Clinical Excellence. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care. 2008. www.nice.org.uk/CG69.
4. Goossens H, Ferech M, Vander Stichele R, Elseviers M; ESAC Project Group. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. Lancet 2005;365:579-87.[Web of Science][Medline]
5. Bertin L, Pons G, d’Athis P, Maudelonde C, Duhamel J, Olive G. Randomised double blind multicenter controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of the symptoms of tonsillitis and pharyngitis in children. J Pediatr 1991;119:811-14.[CrossRef][Web of Science][Medline]
6. Shah S, Sander S, White C, Rinaldi M, Coleman C. Evaluation of echinacea for the prevention and treatment of the common cold: a meta-analysis. Lancet Infect Dis 2007;7:473s-80s.[CrossRef]
7. Little P, Gould C, Williamson I, Warner G, Gantley M, Kinmonth A. Clinical and psychosocial predictors of illness duration from a randomised controlled trial of prescribing strategies for sore throat. BMJ 1999;319:736-7.[Free Full Text]
8. McKee M, Waddell J, Kudo P, Schemitsch E, Richards R. Osteonecrosis of the femoral head in men following short-course corticosteroid therapy: a report of 15 cases. CMAJ 2001;164:205-6.[Free Full Text]
9. Singh J, Palda V, Stanbrook M, Chapman K. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease. A systematic review. Arch Intern Med 2002;162:2527-36.[Abstract/Free Full Text]
10. Van der Beek D, de Gans J, McIntyre P, Prasad K. Corticosteroids for acute bacterial meningitis. Cochrane Database Syst Rev 2007;(1):CD004405.
11. Smith M, Iqbal S, Roew B, N’Diaye T. Corticosteroids for hospitalised children with acute asthma. Cochrane Database Syst Rev 2003;(2):CD002886.
12. Rowe B, Spooner C, Ducharme F, Brezlaff J, Bota G. Early emergency department treatment of acute asthma with systemic corticosteroids. Cochrane Database Syst Rev 2002;(1):CD002178.

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Corticosteroids for pain relief in sore throat: systematic review and meta-analysis

Gail Hayward, Matthew Thompson, Carl Heneghan, Rafael Perera, Chris Del Mar, and Paul Glasziou
BMJ 2009 339: b2976. [Abstract] [Full Text] [PDF]

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