Monday, July 15, 2013

Steroids for pharyngitis?

- Jennifer Middleton, MD, MPH

This month, The Journal of Family Practice (JFP) published a review of a recent Cochrane meta-analysis regarding the use of steroids for patients with "exudative or severe sore throat." The Cochrane researchers found that even one dose of a corticosteroid (either dexamethasone PO, dexamethasone IM, or prednisone PO) increased the number of patients who reported resolution of pain in twenty-four hours (number needed to treat [NNT] = 4).  The Cochrane researchers included studies of patients with both viral and bacterial pharyngitis.

Despite evidence-based tools such as the modified Centor score, which can determine the pre-test probability of streptococcal pharyngitis and guide treatment (described nicely in this AFP article), physicians still overprescribe antibiotics for upper respiratory infections, including pharyngitis.  This AFP by Topic on Upper Respiratory Infections provides a useful review of current treatment guidelines for these prevalent conditions; several articles in that grouping advise caution regarding overuse of antibiotics.  It may be that patients with painful pharyngitis don't necessarily want antibiotics, though, but just something to control their pain.  This new Cochrane meta-analysis, with that excellent NNT regarding improvement of pain after only one day of treatment with a steroid, suggests that steroids may be another useful tool in our pharyngitis treatment kit.

The JFP reviewers are quick to point out that these corticosteroids weren't used alone; the studies in the meta-analysis used them in addition to either antibiotics or analgesics.  Hopefully we will see some randomized controlled trials (RCTs) in the next few years that determine whether steroids are useful by themselves for patients not needing an antibiotic. In the meantime, since the RCTs in the Cochrane meta-analysis used varying methods, we don't have a clear guideline about which patients might benefit or what dose and administration route of corticosteroid to use.

Do you already prescribe steroids for patients with severe pharyngitis (viral or bacterial)?  If not, would this Cochrane meta-analysis encourage you to try it?

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