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Steroids Alone Are Not a Quick Fix for Sore Throats

A single dose of oral corticosteroids in the absence of antibiotics does not help patients with a sore throat feel better quicker, data from a randomized controlled trial show. Moreover, the steroid treatment does not reduce antibiotics use.

At 24 hours, patients who received steroid treatment were no more likely to have complete resolution of acute sore throat pain than those who received placebo, Gail Nicola Hayward, PhD, from the University of Oxford, United Kingdom, and colleagues report in an article published in the April 18 issue of JAMA.

The single-dose steroid treatment did lead to a significant increase in the proportion of patients experiencing complete symptom resolution at 48 hours, which was a secondary trial endpoint. However, based on the high number of patients (n = 12) who need to be treated for one of them to benefit, "our study findings do not support the routine use of steroids for sore throats in primary care," Dr Hayward explains in a video that accompanies the report.

In a previously published systematic review, Dr Hayward and colleagues found that a single dose of oral corticosteroids in addition to antibiotic therapy significantly increased the likelihood of complete resolution of acute throat pain within 24 hours. Therefore, in the current trial, they sought to assess the clinical effectiveness of a single dose of oral dexamethasone compared with placebo among adults aged 18 years or older with acute sore throat not requiring immediate antibiotic therapy.

Of 565 eligible adults presenting to 42 family practices in South and West England between April 2013 and February 2015 with acute sore throat who did not require immediate antibiotics, 288 received a single oral dose of 10 mg dexamethasone and 277 received a matched placebo on the day of their clinic visit. The primary study outcome was complete resolution of symptoms at 24 hours, and secondary outcomes were complete resolution at 48 hours, duration of moderately bad symptoms, further healthcare visits related to sore throat, use of over-the-counter and prescription medications, adverse events, and time away from school or work.

The number of patients achieving complete symptom resolution at 24 hours was statistically similar in the intervention and control groups (22.6% vs 17.7%; P = .144). Also, no significant differences were observed in duration of moderately bad symptoms, further healthcare visits related to the sore throat, and prescription drug use, adverse events or time away from school or work.

At 48 hours, 35.4% of patients in the steroid group overall experienced complete resolution compared with 27.1% of the placebo group (P = .031). A similar between-group difference was observed among those participants who were not offered a delayed antibiotic prescription, with 37.6% in the treatment group and 27.2% in the placebo group experiencing full resolution within 48 hours (relative risk, 1.37; 95% CI, 1.01 - 1.87; P = .046), "but no significant difference was observed for participants offered a delayed prescription," the authors write.

The likelihood of full symptom resolution at 24 or 48 hours was not influenced by severity of sore throat pain at baseline or with a positive streptococcus finding on throat swab, the authors write.

The observed likelihood of complete symptom resolution at 24 hours "was lower than effect sizes reported in previous studies of use of oral corticosteroids in sore throat, which reported RRs ranging from 1.67 to 4.41," the authors report. They note, however, that in previous trials antibiotics were given to both corticosteroid and placebo groups. "It is possible that there is a synergistic effect of corticosteroids and antibiotics when treating sore throat, such as that suggested for acute sinusitis, for which oral corticosteroid monotherapy was ineffective for symptom relief in a primary care–based trial, but corticosteroids in addition to antibiotics offer evidence of benefit," they write.

It is also possible that corticosteroids might be most beneficial for patients with severe sore throat, and that such patients might have fall outside of the current study population, which, by design, did not include participants requiring immediate antibiotics. "More severe symptoms might correlate with more severe inflammation and therefore the anti-inflammatory benefits of corticosteroids would be greater in this patient group," the authors write. "In this trial the test of interaction between severity or streptococcal presence and outcome revealed no significant effect, but this analysis was limited by the small number of participants in these groups."

The takeaway message from the current investigation is that "steroids did not reduce the overall burden of symptoms for patients, did not reduce time off work and did not reduce the amount of antibiotics used," Dr Hayward explains in the video report. "We did find that they improved the chances of complete resolution of symptoms at 48 hours, but this needs to be taken in the context of the short and long-term side effects of steroids and we don't think in this context it's a clinically significant difference."

Sore throat is a common reason for primary care visits, accounting for nearly 6.6 million patient visits in the United States each year, according to the investigators. "We know that most sore throats can get better without antibiotics, but family doctors still prescribe antibiotics to over half of the patients they see with sore throat," Dr Hayward continued. "The more antibiotics you take the more at risk you are of developing an infection that is resistant to antibiotics in the future so it's important that researchers try to find new alternative treatment for sore throat which don't involve antibiotics."

This study was supported by the National Institute for Health Research School for Primary Care Research. One coauthor has disclosed financial relationships with Alere Inc, Roche Molecular Diagnostics, and Phoresa Inc. Another coauthor disclosed receiving funding from the World Health Organization, the National Institute for Health Research, the National Institute for Health Research School of Primary Care Research, and the Wellcome Trust. The other authors have disclosed no relevant financial relationships.

JAMA. 2017;317:1535-1543.

SOURCES:

Steroids Alone Are Not a Quick Fix for Sore Throats. Medscape. April 20, 2017.


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