Re: Corticosteroids for sore throat: a clinical practice guideline
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