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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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Rapid Response:

Corticosteroids for sore throat: do the benefits outweigh the harms?

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

25 September 2017
Gina Johnson
Clinical Tutor
National Minor Illness Centre
Churchfield Medical Centre, Luton