Clinical Question

Is treating sore throat with corticosteroids safe and effective?

Evidence-Based Answer

In adults with suspected bacterial pharyngitis who require antibiotic therapy, adding a corticosteroid may increase the likelihood of complete pain resolution at 24 hours. Further study is needed to assess the safety of corticosteroids and whether they can be recommended for presumed viral pharyngitis or for children. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Pain caused by inflammation from viral or bacterial infection in the oropharynx or tonsils is a common reason that children and adults seek medical care. Many infections are likely caused by rhinovirus, coronavirus, and adenovirus, whereas the most common bacterial pathogen, group A beta-hemolytic streptococcus, is found in 10% of adults and in 15% to 30% of children with sore throat.^1,2 Despite limited benefit of antibiotic therapy, prescribing rates remain inappropriately high; 40% to 50% of sore throat visits result in an antibiotic prescription.³ Analgesics have unclear benefit in pain reduction.⁴ Corticosteroids are used for their anti-inflammatory effects in other respiratory infections and may present an effective treatment for the pain of sore throat.

The authors searched for randomized controlled trials that compared any corticosteroid use vs. usual care or placebo in adults and children older than three years who presented with sore throat to outpatient clinics or emergency departments. The review included eight trials with 743 patients. Two trials enrolled only children, two enrolled only adults, and four included both age groups. Antibiotics were used in all eight trials. In two trials, antibiotics were prescribed only to patients who tested positive for group A streptococcus. One trial enrolled only patients with test-positive streptococcal pharyngitis. In the remaining five trials, pharyngitis was diagnosed clinically, and antibiotic use was recommended either for all patients or by physician discretion.

High-quality evidence from four studies with 286 patients showed that participants who received corticosteroids were three times more likely to be pain free at 24 hours than those who received placebo (number needed to treat = 3.7). Moderate-quality evidence from six of the eight studies found that pain relief also started an average of six hours earlier in those treated with corticosteroids vs. placebo (P < .001). Included trials used oral or intramuscular corticosteroids, or both, with a single dose or two- or three-day treatment courses. Subgroup analyses to determine the optimal route or dosing regimen were not statistically significant, although corticosteroids tended to be more effective in patients with severe exudative bacterial pharyngitis than in those with milder symptoms or nonstreptococcal pharyngitis.

Of the two trials that enrolled only children, one reported a positive effect with corticosteroid use, and the other found no difference between the treatment groups. The studies that enrolled children, adolescents, and adults did not report outcomes by age, so reviewers were unable to stratify effectiveness by age group. No significant differences were noted in adverse event rates, complications of streptococcal disease, or recurrence or relapse rates between the corticosteroid and placebo groups, although conclusions regarding safety were limited because of the small number of trials.

The 2012 guidelines from the Infectious Diseases Society of America, which pooled recommendations from studies of children and adults, recommend against the use of corticosteroids for the symptoms of acute bacterial pharyngitis.⁵ Although corticosteroids may be an effective adjunct treatment for the pain of sore throat in adolescents and adults, further study is needed to confirm effectiveness in children and as a potential stand-alone treatment in trials without antibiotics.