Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, et al. Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials. BMJ. 2017 Sep 20;358:j3887. doi: 10.1136/bmj.j3887.
Area Score
Pediatrics (General)
Family Medicine (FM)/General Practice (GP)
General Internal Medicine-Primary Care(US)
Abstract

Objective To estimate the benefits and harms of using corticosteroids as an adjunct treatment for sore throat.Design Systematic review and meta-analysis of randomised control trials.Data sources Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists of eligible trials, related reviews.Study selection Randomised controlled trials of the addition of corticosteroids to standard clinical care for patients aged 5 or older in emergency department and primary care settings with clinical signs of acute tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were included irrespective of language or publication status.Review methods Reviewers identified studies, extracted data, and assessed the quality of the evidence, independently and in duplicate. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. Random effects model was used for meta-analyses. Quality of evidence was assessed with the GRADE approach.Results 10 eligible trials enrolled 1426 individuals. Patients who received single low dose corticosteroids (the most common intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as likely to experience pain relief after 24 hours (relative risk 2.2, 95% confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to 1.8; risk difference 18.3%; high quality). The mean time to onset of pain relief in patients treated with corticosteroids was 4.8 hours earlier (95% confidence interval -1.9 to -7.8; moderate quality) and the mean time to complete resolution of pain was 11.1 hours earlier (-0.4 to -21.8; low quality) than in those treated with placebo. The absolute pain reduction at 24 hours (visual analogue scale 0-10) was greater in patients treated with corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9; moderate quality). Nine of the 10 trials sought information regarding adverse events. Six studies reported no adverse effects, and three studies reported few adverse events, which were mostly complications related to disease, with a similar incidence in both groups.Conclusion Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat.Systematic review registration PROSPERO CRD42017067808.

Comments from MORE raters

Family Medicine (FM)/General Practice (GP) rater

I would differ with the authors' statement that "Corticosteroids are not commonly prescribed." In my experience, they are prescribed frequently for sore throats, usually by doctors who don't read the literature all that regularly. It is worthwhile to see that the practice is appropriate, and that the dose should be much less than is routinely given.

Family Medicine (FM)/General Practice (GP) rater

I have trouble with giving corticosteroids, even one dose, for symptoms that will resolve spontaneously. I would think trials evaluating the combination of sore throat and difficulty swallowing are more appropriate for determining benefit.

General Internal Medicine-Primary Care(US) rater

The meta-analysis suggests one or two steroid doses may reduce the discomfort patients experience with a sore throat. This relatively low-risk intervention appears to have a clinically significant effect with both a lower pain score at 24 hours and pain resolution at 48 hours. Given the multitude of possible interventions for sore throat with no proven efficacy, it's great to see an evidence-based option to provide to our clinicians and patients. I believe this meta-analysis should help shift clinical practice.

General Internal Medicine-Primary Care(US) rater

I noticed that the ER docs were doing this. I enjoyed reading this article and I think I may prescribe steroids the next time I see someone with a terrible sore throat. Practice changing.

General Internal Medicine-Primary Care(US) rater

Corticosteroids, as studied in this review, appear to have a relatively small clinical benefit with respect to pain relief.

General Internal Medicine-Primary Care(US) rater

Excellent clinical relevance that is useful in day-to-day practice.