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Practice Rapid Recommendations

Corticosteroids for sore throat: a clinical practice guideline

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j4090 (Published 20 September 2017) Cite this as: BMJ 2017;358:j4090

Population

This recommendation applies to almost all patients with sore throat: People withsore throat Children and adults Emergency and primary care settings Patients with a viral or bacterial sore throat Severe and not severe sore throat Patients who receive immediate or deferred antibiotics However the recommendation is not applicable to patients with: Infectiousmononucleosis Immunocompromising conditions Sore throat following surgery or intubation

Choice of intervention

or Short course of steroids No steroids Standard clinical care, which typically includes analgesics, and may include antibiotics 1–2 doses of oral Dexamethasone(or equivalent dose of alternative corticosteroid) + standard care 10mg Adults: Children: Standard care Analgesics Antibiotics 0.6mg per kg + +/- + Standard care Analgesics Antibiotics + +/-

Recommendation

Favours steroids Favours no steroids

We suggest short course steroids. Discuss with patients in shared decision making. All Applies to Click for details Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Weak Benefits outweigh harms for the majority, but not for everyone. The majority of patients would likely want this option. Strong Benefits outweigh harms for almost everyone. All or nearly all informed patients would likely want this option.

Comparison of benefits and harms

Favours Steroids Favours no steroids Evidence quality Events per 1000 people No important difference The panel found that these differences were not important for most patients, because the intervention effects were negligible and/or very imprecise (such as statistically not significant)

124 more Complete pain resolution (24 hrs) Moderate More 100 224

Risk of Bias No concerns Imprecision Serious Indirectness No concerns Inconsistency Due to imprecision Publication bias No concerns Corticosteroids probably increase the chance of complete resolution of pain at 24 hours

204 more More Complete pain resolution (48 hrs) High 629 425

Risk of Bias No concerns Imprecision No concerns Indirectness No concerns Inconsistency No concerns Publication bias No concerns Corticosteroids increase the chance of complete resolution of pain at 48 hours
Mean time to resolution (hours)

11.1 fewer More Complete pain resolution Low 33.0 44.0

Risk of Bias No concerns Imprecision Serious Indirectness No concerns Inconsistency Serious Publication bias No concerns Corticosteroids may shorten the duration of pain
Events per 1000 people

More Symptom recurrence or relapse Moderate 34 65 No important difference

Risk of Bias No concerns Imprecision Serious Indirectness No concerns Inconsistency No concerns Publication bias No concerns Corticosteroids probably have no important effect on the chance that symptoms recur

Antibiotics prescription Low 564 468 96 fewer More

Risk of Bias No concerns Imprecision Very serious Indirectness No concerns Inconsistency No concerns Publication bias No concerns Corticosteroids may decrease the chance of taking antibiotics in patients given a prescription with instructions to take the antibiotic if unimproved or worse.
See all outcomes
The panel believes that there is a great variability on how much reduction in pain severity or time to complete pain resolution each patient would consider important. Shared decision making may help establish what matters most to each patient. Preferences and values Serious adverse events Multiple doses One-dose administration of steroids is not likely to cause serious adverse events. Very low quality evidence exists for extremely rare but serious adverse effects following higher doses or longer courses of steroids (up to 30 days). Risks may outweigh benefits when cumulative doses of steroids are given for multiple episodes of sore throat. To mitigate this issue, clinicians could administer the medication in office if possible, or prescribing only one dose per visit. Key practical issues Steroids No steroids 1–2 doses, taken as pill(s) or intramuscular injection(s) No practical issues May cause transient sleep disturbance, and excitability Dexamethasone is generally avoided during pregnancy

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Find recommendations, evidence summaries and consultation decision aids for use in your practice
  1. Bert Aertgeerts, general practitioner, professor1 2,
  2. Thomas Agoritsas, general internist, assistant professor3 4,
  3. Reed A C Siemieniuk, general internist, methodologist3 5,
  4. Jako Burgers, general practitioner, professor6 7,
  5. Geertruida E Bekkering, methodologist1 2,
  6. Arnaud Merglen, pediatrician8,
  7. Mieke van Driel, general practitioner, professor9,
  8. Mieke Vermandere, general practitioner1,
  9. Dominique Bullens, paediatrician, professor10 11,
  10. Patrick Mbah Okwen, general practitioner12,
  11. Ricardo Niño, otorhinolaryngologist13,
  12. Ann van den Bruel, general practitioner, associate professor14 15,
  13. Lyubov Lytvyn, patient liaison expert16,
  14. Carla Berg-Nelson, patient representative17 18,
  15. Shunjie Chua, patient representative19,
  16. Jack Leahy, patient representative20,
  17. Jennifer Raven, patient representative21,
  18. Michael Weinberg, patient representative22,
  19. Behnam Sadeghirad, methodologist3 23,
  20. Per O Vandvik, general internist, associate professor15 24,
  21. Romina Brignardello-Petersen, methodologist and biostatistician2 25
  1. 1Academic Centre for General Practice, Department of Public Health and Primary Care, KU Leuven, Belgium
  2. 2CEBAM, Belgian Centre for Evidence-Based Medicine, Cochrane Belgium, Leuven, Belgium
  3. 3Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada L8S 4L8
  4. 4Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, CH-1211, Geneva, Switzerland
  5. 5Department of Medicine, University of Toronto, Toronto, Ontario, Canada
  6. 6Dutch College of General Practitioners, Utrecht, The Netherlands
  7. 7School CAPHRI, Department Family Medicine, Maastricht, The Netherlands
  8. 8Division of General Pediatrics, University Hospitals of Geneva & Faculty of Medicine, University of Geneva, Geneva, Switzerland
  9. 9Primary Care Clinical Unit, Faculty of Medicine, University of Queensland, Brisbane, Australia
  10. 10Pediatric Immunology, Department of microbiology and immunology, KU Leuven, Belgium
  11. 11Pediatric allergy, Clinical division of pediatrics UZ Leuven, Leuven, Belgium
  12. 12Bali District Hospital, Bali and Centre for Development of Best practices in Health Yaounde, Cameroon
  13. 13Otorhinolaryngology—Head and Neck Surgery, Clinica del Country, Bogota, Colombia
  14. 14NIHR Oxford Diagnostic Evidence Cooperative, Oxford, UK
  15. 15Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
  16. 16Oslo University Hospital, Forskningsveien 2b, Blindern 0317 Oslo, Norway
  17. 17The Society for Participatory Medicine, Newburyport, MA 01950-1183, USA
  18. 18Arizona Senior Academy, Tucson, AZ 85747, USA
  19. 19MOH Holdings, 1 Maritime Square, Singapore, Singapore 099253
  20. 20Cochrane UK, London, UK
  21. 21Cochrane Consumers Group, Halifax, Canada
  22. 22Washington DC, USA
  23. 23HIV/STI Surveillance Research Center, and WHO Collaborating Center for HIV Surveillance, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
  24. 24Department of Medicine, Innlandet Hospital Trust - division Gjøvik, Norway
  25. 25Faculty of Dentistry, Universidad de Chile, Santiago, Chile
  1. Correspondence to: B Aertgeerts bert.aertgeerts{at}kuleuven.be

What is the role of a single dose of oral corticosteroids for those with acute sore throat? Using the GRADE framework according to the BMJ Rapid Recommendation process, an expert panel make a weak recommendation in favour of corticosteroid use. The panel produced these recommendations based on a linked systematic review triggered by a large randomised trial published in April 2017. This trial reported that corticosteroids increased the proportion of patients with complete resolution of pain at 48 hours. Box 1 shows all of the articles and evidence linked in this Rapid Recommendation package. The infographic provides the recommendation together with an overview of the absolute benefits and harms of corticosteroids in the standard GRADE format. Table 2 below shows any evidence that has emerged since the publication of this article. Clinicians and their patients can find consultation decision aids to facilitate shared decision making in MAGICapp (www.magicapp.org/goto/guideline/JjXYAL/section/j79pvn).

What you need to know:

  • Sore throat is one of the most common reasons for primary care appointments, and international guidance varies about whether to use corticosteroids to treat it, but a trial published in April 2017 suggested that costicosteroids might be effective

  • We make a weak recommendation to use a single dose of oral corticosteroids, in those presenting with acute sore throat, after performing a systematic review of the new evidence in this rapid recommendation publication package

  • The recommendation is weak and shared decision making is needed because corticosteroids did not help all patient reported outcomes and patients’ preferences varied substantially

  • Steroids somewhat reduced the severity and duration of pain by one day, but time off school or work was unchanged. Harm seems unlikely with one steroid dose.

  • The treatment is inexpensive and likely to be offered in the context of a consultation that would have taken place anyway

Box 1: Linked articles in this BMJ Rapid Recommendations cluster

  • Aertgeerts B, Agoritsas T, Siemieniuk RAC, …

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