Resident Clinical Pearl – Pharyngitis

“Doc, you gotta’ help me”: corticosteroids as an adjuvant for pharyngitis

Resident Clinical Pearl – December 2015

Kavish Chandra, R1 FMEM, Dalhousie University, Saint John, New Brunswick

Reviewed by: Dr Matt Greer and Dr David Lewis

Pharyngitis is a common presenting complaint in the EDs and primary care practices. The etiology of pharyngitis most commonly is viral in origin (rhinovirus, coronavirus and adenovirus); however, other infectious etiologies include bacteria, fungi and parasites.1 Of the bacterial causes, group A beta-hemolytic Streptococcus (GABHS) is the most common pathogen, representing 15% of pharyngitis cases in adults and 15 to 30% in children (1).

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There are several treatment algorithms for the treatment of GABHS, and varying treatments for the other etiologies of pharyngitis. While physicians often assume that patients are seeking antibiotics for the treatment of their pharyngitis, a major treatment goal for patients is to improve their pain and swallowing.2 Some advocate for the addition of a single dose of dexamethasone in moderate to severe cases, which may shorten the duration of pain (2).

 

The Question:

How effective are corticosteroids as an adjuvant in the treatment of pharyngitis?

A Cochrane review in 2012 looked 8 randomized-controlled trials which included 743 adult and pediatric patients with tonsillitis, pharyngitis, sore throat and/or odynophagia treated with either corticosteroids or placebo (3). The meta-analysis included out-patients in the ED or in primary care practices and excluded in-patients, patients with infectious mononucleosis, post-surgery or peritonsillar abscesses. Primary outcomes were: resolution of pain and mean time to onset of pain relief. Corticosteroids included betamethasone (8mg), dexamethasone (up to 10mg) or prednisone (60mg), and were administered either orally or intramuscularly. All patients received antibiotics and other analgesia. In addition to antibiotics and analgesia, the administration of corticosteroids increased the likelihood of complete pain resolution at 24 hours by 3.2 times and by 1.7 times at 48 hours, NNT of 3.3 and 3.7 respectively. The administration of corticosteroids reduced the mean time to onset of pain relief by 6 hours and 14.4 hours for complete pain resolution. There were no differences in adverse effects in the corticosteroid and placebo groups.

 

Limitations of the review: all patients were treated with an antibiotic and analgesia in addition to a corticosteroid in the treatment arm. Therefore, studies are needed to assess the effectiveness of corticosteroids as stand-alone therapy. Two trials included only children, and because of the small number of participants in each RCT, there was high heterogeneity and inconsistent results in that group of patients. The meta-analysis was also underpowered to detect adverse effects; however, the short courses of corticosteroids are unlikely to be harmful.

 

Bottom Line:

In conjunction with antibiotic therapy, corticosteroids can reduce pain and decrease time to complete resolution of pain in patients with pharyngitis.

 

References

  1. Cline, D. (2013). Infections and disorders of the neck and upper airway. (3rd ed.) Tintinalli’s emergency medicine: Just the facts (pages 550-555). New York: McGraw-Hill.
  1. Korb, K., Scherer, M., & Chenot, J. F. (2010). Steroids as adjuvant therapy for acute pharyngitis in ambulatory patients: A systematic review. Annals of Family Medicine, 8(1), 58-63. http://www.annfammed.org/content/8/1/58.full.pdf+html
  1. Hayward, G., Thompson, M. J., Perera, R., Glasziou, P. P., Del Mar, C. B., & Heneghan, C. J. (2012). Corticosteroids as standalone or add-on treatment for sore throat. The Cochrane Database of Systematic Reviews, 10, CD008268. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008268.pub2/pdf

 

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