The Case

A teenager with a high pain tolerance presents to your Emergency Department with pharyngitis. They had a negative strep, COVID-19 antigen, and flu swab earlier in the week at their primary doctor’s office. Based on the mildly exudative pharyngitis, fever, slight splenomegaly and malaise you (correctly) diagnose them with mononucleosis. The parent’s main concern is making sure that they will be able to stay hydrated because of how much pain with swallowing they are having. Ibuprofen and acetaminophen are helping – but only somewhat and you are asked if there’s anything else you can do?

Corticosteroids for acute pharyngitis

Can giving a dose of corticosteroid (generally Dexamethasone) improve pain in patents with pharyngitis? Let’s take a look at the evidence, specifically two large systematic reviews…

Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials – BMJ, 2017

This systematic review and meta-analysis of 10 randomized control trials that evaluated the addition of corticosteroids to standard clinical care for patients >5 years in outpatient or ED settings with sore throat. In total there were over 1,600 patients in these 10 studies. Most used low dose steroids, generally dexamethasone ≤0.6mg/kg/dose (max 10mg). Those who received steroids were…

  • A little more than twice as likely to have pain relief after 24 hours, RR = 2.2 (95%CI, 1.2 to 4.3) and absolute risk difference 12.4% (moderate quality of evidence)
  • One and a half times more likely to have no pain at 48 hours RR = 1.5 (95% CI, 1.3 to 1.8) and absolute risk difference 18.3% (high quality of evidence)
  • Pain relief just under 5 hours earlier – mean time 4.8 hours (95% CI, -1.9 to -7.8) (moderate quality of evidence)
  • Mean time to complete resolution of pain vs placebo was 11.1 hours earlier (95% CI, -0.4 to -21.8) (low quality of evidence)
  • Absolute pain reduction at 24 hours (visual analogue scale 0-10) was also greater with corticosteroids (mean difference 1.3 (95% CI, 0.7 to 1.9) (moderate quality of evidence)
  • 9 of the 10 trials looked at side effects and adverse events and saw no additional ones due to the steroids alone

Corticosteroids as standalone or add-on treatment for sore throat – Cochrane database for systematic reviews, 2020

This Cochrane systematic review included 9 trials with 1319 patients (369 children and 950 adults). In 8/9 trials patients in both corticosteroid and placebo groups received antibiotics – the other offered delayed prescription of antibiotics. The cumulative results in addition to the effects of antibiotics and analgesics are as follows;

  • Corticosteroids increased the likelihood of complete resolution of pain at 24 hours, RR = 2.4, (95% CI, 1.29 to 4.47; P = 0.006; I²= 67%) (high-certainty evidence)
  • Pain resolution was also greater at 48 hours, RR = 1.50 (95% CI, 1.27 to 1.76; P<0.001; I²= 0%) (high-certainty evidence)
  • The number needed to treat (NNT) to prevent one person continuing to experience pain at 24 hours was 5
  • Corticosteroids reduced the mean time to onset of pain relief by 6 hours, and the mean time to resolution by 11.6 hours (moderate-certainty evidence)
  • At 24 hours pain was reduced by ~10.6% by corticosteroids (moderate-certainty evidence)
  • No differences in relapse rates, days missed from work or school, or adverse events were seen – but reporting of such events was limited, especially in kids

The bottom line

The cumulative evidence suggests that a single dose of oral or IM corticosteroid (dexamethasone) can meaningfully reduce the quantity and length of pain in children and adolescents with sore throat diagnoses that do and do not require antibiotics. The level of evidence varies across studies – but as long as the diagnosis is certain (not a malignancy) and the child has no contraindications to getting a corticosteroid, then shared decision making with parents, caregivers, and patients about a single dose of dexamethasone is reasonable. I would give a dose of dex to this patient in question, because I think it may keep them from needing to return to the ED and can help them achieve better pain relief sooner – as long as they are still using ibuprofen or acetaminophen.

References

Aertgeerts B, Agoritsas T, Siemieniuk RAC, Burgers J, Bekkering GE, Merglen A, van Driel M, Vermandere M, Bullens D, Okwen PM, Niño R, van den Bruel A, Lytvyn L, Berg-Nelson C, Chua S, Leahy J, Raven J, Weinberg M, Sadeghirad B, Vandvik PO, Brignardello-Petersen R. Corticosteroids for sore throat: a clinical practice guideline. BMJ. 2017 Sep 20;358:j4090. doi: 10.1136/bmj.j4090. Erratum in: BMJ. 2017 Dec 5;359:j5654. PMID: 28931507; PMCID: PMC6284245.

de Cassan S, Thompson MJ, Perera R, Glasziou PP, Del Mar CB, Heneghan CJ, Hayward G. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2020 May 1;5(5):CD008268. doi: 10.1002/14651858.CD008268.pub3. PMID: 32356360; PMCID: PMC7193118.

Sadeghirad B, Siemieniuk RAC, Brignardello-Petersen R, Papola D, Lytvyn L, Vandvik PO, Merglen A, Guyatt GH, Agoritsas T. 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. PMID: 28931508; PMCID: PMC5605780.