Caveats: Questions about effects on antibiotic use, heterogeneity remain
The studies in this meta-analysis did not assess whether the use corticosteroids would reduce unnecessary use of antibiotics, so we cannot conclude that this would be the case. Because the effect was similar in all sub-groups analyzed, however, it is reasonable to expect that reduced antibiotic use could be a positive effect. The main documented benefit was resolution of pain, an important patient-centered outcome that justifies consideration of treating painful pharyngitis with corticosteroids.
Corticosteroids have an immunosuppressant effect and carry the theoretical risk of exacerbating an existing infection. That did not occur in these studies. Nor has it occurred when used for short courses in other illnesses such as croup, infectious mononucleosis, asthma, contact dermatitis, and chronic obstructive pulmonary disease.14 Thus, this theoretical risk is not a barrier to implementation.
It is important to note that single and multiple doses of corticosteroids and oral and IM routes were effective, with only minimal differences in results.
Challenges to implementation: Determining the severity
Acetaminophen and NSAIDs are used for pain relief in sore throat, and have been shown to be effective—but may be inadequate for severe pain.15 There are no head-to-head trials that have compared steroids to NSAIDs or acetaminophen in this clinical scenario. So the challenge for clinicians will be to decide when pharyngitis is severe enough to justify the use of corticosteroids, rather than simple analgesics alone.
Acknowledgement
The PURLs Surveillance System was supported in part by Grant number ul1rr024999 from the national center for research resources, a clinical Translational Science award to the university of chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of the national center for research resources or the national institutes of health.
