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:j4090Population
Choice of intervention
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All rapid responses
Having studied adult sore throats for over 35 years, the recent use of corticosteroids seems strange. I do not understand this guideline. First, the sentence confounded me: "Most infections are of viral origin; only a few are caused by a bacterial infection, of which group A β-haemolytic streptococcus, Haemophilus influenzae, and Moraxella catarrhalis are the most common pathogens". I know of no data on either H. flu or Moraxella causing sore throats. They are causes of community acquired pneumonia. Group C strep and Fusobacterium necrophorum do cause sore throats in adolescents and young adults.
This error makes one wonder about the development of this guideline.
The evidence for corticosteroid use (as Dr. Linder makes clear ) is weak at best. While 1 dose likely will not cause and major side effects, it could mask worsening symptoms and delay diagnosis of suppurative complications. The benefits seem minimal.
This "guideline" is merely expert advice. It is really a guidance statement. I disagree with the guideline.
Competing interests: No competing interests
Dear Authors,
As an ENT trainee doctor, we often see patients with sore throats (tonsillitis, EBV or Quinsey). From experience and internal audits, the vast majority of presenting sore throat to the hospital setting is tonsillitis. It is common practice to treat these patients with corticosteroids, especially when not eating and drinking. From looking at the responses of the clinicians in the primary care setting, it may not be common practice to prescribe steroids for sore throats, as it is a self-limiting condition. I wonder if the use of steroids has more application in the secondary care setting, in terms of improving symptoms and subsequently reduced inpatient hospital stays.
Kind Regards
Competing interests: No competing interests
We thank Dr. Linder for taking the time to consider and respond to our recommendation. A focus on hypothesis testing (and p-values) within individual studies can be misleading for a variety of reasons. Individual studies might be underpowered or overpowered, and p-values tell us nothing about the effect size or the importance of the outcomes. Instead of vote counting significant p-values, we and the GRADE approach suggest a focus confidence intervals around the absolute treatment effects for each patient-important outcome. We perform this assessment across the whole body of evidence, including the study by Hayward and colleagues, which provided the impetus for this Rapid Recommendation. The Hayward study's results are for the most part consistent with the results of the other nine randomised trials. As summarized in our infographic and in the systematic review supporting this recommendation (http://www.bmj.com/content/358/bmj.j3887), we also considered other factors contributing to the certainty of effects, namely the risk of bias, indirectness, inconsistency, and publication bias. Our panel considered all these factors across the entirety of the evidence base to issue the Rapid Recommendation.
Competing interests: No competing interests
I remain stunned that the JAMA paper by Hayward and colleagues was considered "positive" and was the impetus for this updated, rapid review.
This was a negative study. The primary outcome, complete resolution at 24 hours, was negative. Only 1 -- complete resolution at 48 hours -- of about 8 secondary outcomes was positive. This was probably due to the play of chance. There was no difference in the time to resolution of symptoms between the steroid and placebo groups. "There were no significant differences between groups in the use of pain relief medications (topical and oral), antibiotics for sore throat, or antibiotics for other conditions and no differences in the proportion of participants missing any time away from work or education."
Even if the benefit at 48 hours were "real" -- and I am not allowing that it is because all of the other outcomes are negative -- in absolute terms, at 48 hours, only 35% of patients were better compared to 27% in the placebo group, a very small difference with a NNT of 13.
Again, this was a negative study and should not be included in this meta-analysis.
Reference
Hayward GN, Hay AD, Moore MV, Jawad S, Williams N, Voysey M, Cook J, Allen J, Thompson M, Little P, Perera R, Wolstenholme J, Harman K, Heneghan C. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in AdultsA Randomized Clinical Trial. JAMA. 2017;317(15):1535–1543. doi:10.1001/jama.2017.3417
Competing interests: No competing interests
We appreciate the discussion triggered by our trustworthy recommendation where we suggest to offer steroids for people with a sore throat attending their primary care physician. Most of the comments spoke from a societal point of view. We acknowledge the potential challenges such a change in practice may raise for health care systems, including a potential increase in consultations and opportunity costs that may follow. Careful readers would hopefully have noted that we take an individual patient perspective, rather than a system perspective, in creating the recommendations. Indeed, we encourage scrutiny and adaptation of the recommendations to contextualize to particular settings such as the NHS if needed. We hope those in need of adapting recommendations will follow standards for trustworthy guidelines and be explicit and transparent about judgments made when potentially arriving at modified recommendations against steroids for acute sore throat.
Responders to our Rapid Recommendations state that there is a small extent of benefit, and the magnitude of benefit is insufficient to warrant a visit to the physician. This judgment is not, however, appropriately in the domain of the clinician, but rather in that of the patient. An individual whose every swallow is an agony may well disagree that the magnitude of benefit is unimportant. Indeed, our panel, in particular the patients on the panel, considered that the majority of patients – like those included in the trials – whose distress is sufficient to motivate them to make a visit to a health care facility, would judge the reduction in sore throat duration well worth a single dose of dexamethasone. We aim to be transparent about these judgments as reflected in the statement “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.” We issued a weak recommendation to reflect the fine balance between desirable and undesirable consequences and need for shared decision-making.
That is what these Rapid Recommendations are all about. Informing clinicians and patients about current best evidence and bringing this evidence into practice with understandable data. This approach is perhaps to some extent disruptive to current practices in health care but nevertheless well aligned with accepted standards for evidence-based health care and shared decision-making. Patients should - if they would like to - be able to decide together with their clinicians which approach they choose, based upon trustworthy evidence. We believe this approach takes us one step further towards the goal of shared decision making, taking individual patients values and preferences and other factors into account.
Although we suspect that the vision of a tsunami of sore throat sufferers appearing at physicians' doors is unlikely, the system should – in one way or another – accommodate patients who judge the benefit important, and knowing that it is available would now (though not previously) have made a visit to a health care provider. Perhaps the day when a single dose of dexamethasone for sore throat is available at the local pharmacy may not be distant.
Competing interests: No competing interests
I really must take the authors to task for effectively assuming that a consultation is a no-cost option. As our colleague Kevork Hopayian has pointed out in his response, we have worked hard over the last few decades to educate patients away from presenting with self limiting sore throats. The GP part of the NHS is under unprecedented pressure and a recommendation which encourages patients to consult for a self-limiting illness is unwelcome, unwarranted and a profligate disregard of Primary Care's most precious commodity- consultation time.
Whilst I understand that the BMJ is an international publication and other countries may have better funded Primary Care with rapid access, promoting a medical intervention with minimal benefit without including the cost of service delivery seems extraordinarily counter-intuitive.
I await the Rapid Recommendation on how to restore the genie to the bottle....
Competing interests: No competing interests
'The treatment is inexpensive and likely to be offered in the context of a consultation that would have happened anyway'.
I'm afraid this misses the point.
We have spent many years educating our patients to understand that for the vast majority of sore throats there is no useful therapy and that they do not need to attend the doctor each time they develop one.
If we suggest that they should start attending each time -to save 11.1 hours of illness- then we will immediately increase attendances with these very minor problems. This will divert time and energy from more important work and thus add significantly to the burdens our profession is suffering, making it harder for the significantly unwell to access our services -whilst achieving almost nothing.
This looks like research which should have been suppressed for the greater good!
Stephen Haywood
GP Northumberland
Competing interests: No competing interests
As a patient my prime interest is in getting better, but not at the risk of delayed or unknown effects resulting from " treatment".
As a retired doctor, I have some interest in " what", " how", "why" of disease and therapy.
The authors WEAKLY recommend steroids.
May I please know:
Have they no interest in knowing WHAT caused the sore-throat?
How often, do THEY, in their practice, take a throat swab? And also specifically ask the lab to look for viruses?
How often do they look for E-B infection?
How often do they find monilial infection?
To the patient representatives I ask:
How often do you ask the doctor - " But, doctor, what is the bug (or pathogen) causing me this trouble?"
Reverting to E-B virus - may I ask experts (the authors perhaps are not experts in this):
Does a dose of steroids pose any oncogenic risks in combination with EBV infection?
Thank you
Competing interests: No competing interests
This article (1) recommends a major change to the management of sore throat in the UK; quite apart from the issue of the increased workload which this would create, I am not convinced that the possible small benefit justifies the risks. By my calculation, the most recent trial included in the review (2) had a NNT of 12 for patients with sore throat who were given dexamethasone being pain-free after 48 hours. That is not impressive.
The authors state that "A single dose of corticosteroids is unlikely to cause serious adverse events". However a recent US cohort study (3) showed that short courses of oral steroids are associated with a fivefold increase in the risk of sepsis in the following 30 days, as well as a threefold risk of VTE and double the risk of fractures. The courses used in this article were for a median dose of 20mg prednisolone and a median duration of 6 days (120mg in total). This new guideline recommends using 10mg of dexamethasone: a high dose of oral steroid, equivalent to 65 mg prednisolone (130mg in total if given for two days).
Certainly oral steroids should be considered as an option for the patient in severe pain, but I do not believe that the existing evidence justifies their routine prescription.
References
1. Aertgeerts Bert, Agoritsas Thomas, Siemieniuk Reed A C, Burgers Jako, Bekkering Geertruida E, Merglen Arnaud et al. Corticosteroids for sore throat: a clinical practice guideline BMJ 2017; 358 :j4090
2. Hayward GN, Hay AD, Moore MV, et al. Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults: a randomized clinical trial. JAMA2017;358:1535-43
3. Waljee Akbar K, Rogers Mary A M, Lin Paul, Singal Amit G, Stein Joshua D, Marks Rory M et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study BMJ 2017; 357 :j1415
Competing interests: No competing interests
Re: Corticosteroids for sore throat: a clinical practice guideline
Can I question the dose of dexamethasone for children? 0.6mg/kg seems like a very large dose, since any child over 17kg would be given a dose higher than the adult dose. The dose for croup is much lower than this. Please can the authors confirm that this is the correct dose.
Competing interests: No competing interests