Intended for healthcare professionals

CCBYNC Open access

Rapid response to:

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

©BMJ Publishing Group Limited.

Disclaimer: This infographic is not a validated clinical decision aid. This information is provided without any representations, conditions or warranties that it is accurate or up to date. BMJ and its licensors assume no responsibility for any aspect of treatment administered with the aid of this information. Any reliance placed on this information is strictly at the user's own risk. For the full disclaimer wording see BMJ's terms and conditions: http://www.bmj.com/company/legal-information/

Find recommendations, evidence summaries and consultation decision aids for use in your practice

Rapid Response:

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

02 October 2017
Bert Aertgeerts
Professor
Guyatt G, Agoritsas T, Vermandere M, Siemieniuk R, Lytvyn L, Brignardello R, Vandvik PO
KU Leuven
Kapucijnenvoer 33, blok J, P7001, 3000 Leuven