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Three Part Question

In [An Immunologically Intact Adult Patient] do [Corticosteroids Reduce Pain and Symptoms] in [Acute Pharyngitis]?

Clinical Scenario

A 35 year old male presents to the Emergency Department complaining of acute sore throat for 24 hours. He finds swallowing extremely painful, and has been having difficulty in eating and drinking today. Examination reveals an acutely inflamed retropharynx with prominent exudate over the tonsils. He has a temperature of 38.5oC and looks flushed, but is not yet dehydrated. You perform a throat swab, with results forwarded to the patient's General Practitioner, and advise on antipyretics, hydration and Aspirin gargles, in the absence of contraindications, but wonder if a brief course of steroids might alleviate symptoms.

Search Strategy

PUBMED Interface on the World Wide Web. 1966-Feb 2004
(dexamethasone OR beclamethasone OR prednisolone OR steroid OR corticosteroid) AND (acute AND (pharyngitis OR tonsillitis))
LIMIT to English Language, Adult and Human

Search Outcome

23 papers of which 3 are directly relevant to the question and of sufficient quality for inclusion

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
O'Brien et al 1993 USA	58 patients aged 12-65 years with exudative pharyngitis and severe dysphagia/odynophagia. Patients with cancer, AIDS, Diabetes Mellitus, recent steroid use, pregnancy or suspicion of peritonsillar abscess excluded. 10mg IM Dexamethasone vs. saline placebo. All patients received oral antibiotics.	Prospective, randomized, double blinded placebo controlled trial	Improvement in pain score (0 to 3.0) at 24 hours.	1.8±0.8 in IM Dexamethasone group vs. 1.2±0.9 in placebo group (P<0.05)	Follow up was 88% at 24 hours, falling to 45% at 7 days. No Power Calculation given.
			Time to onset of pain relief	6.3±5.3 hours in IM Dexamethasone group vs. 12.4±8.5 in placebo group (P<0.02)
			Time to complete lack of pain	15.0±11.4 hours in IM Dexamethasone group vs. 35.4±17.9 hours in placebo group (P<0.02)
Marvez-Valls et al 1998 USA	92 patients aged 14-65 years with sore throat and/or odynophagia, dysphagia, fever or cervical lymphadenopathy with visible evidence of exudative pharyngeal infection and pain. Patients with AIDS, immunocompromise, peritonsillar abscess, thrush, steroid use in last 3 months, diabetes mellitus, ulcerative pharyngitis, pharyngitis without exudates, prior allergy to steroids and inability to consent were excluded. Unknown dose of IM Betamethasone vs. saline placebo. All patients received antibiotics.	Randomized, double blind, placebo controlled trial	Mean decrease in 10cm visual analogue pain score at 24 hours	5.5±2.7 in IM Betamethasone group vs. 3.9± 2.7 in placebo group. P=0.004	Patient and prescribing physician blinded, but nurse administering drug unblinded. 50% of patients reminded of previous pain score at telephone follow up.
			Mean decrease in 10cm visual analogue pain score at 48 hours	6.8±2.7 in IM Betamethasone group vs. 6.2±2.7 in placebo group. P=0.28
			Time to first experiencing pain relief	6.3±8.1 hours in IM Betamethasone group vs. 11.3± 8.1 hours in placebo group. P=0.013
			Time to complete pain relief	42.0±43.3 hours in IM Betamethasone group vs. 55.8±43.9 hours in placebo group. P=0.013
			Number of days school / work missed	0.4±1.4 days in IM Betamethasone group vs. 0.7±1.4 days in placebo group. P=0.19
Wei et al 2002 USA	120 patients aged 15 and above with clinical diagnosis of acute pharyngitis/tonsillitis and physical examination showing erythema with or without exudate in oropharynx. Immunosupressed patients, diabetes mellitus, HIV positive, history of head or neck malignancy, recent (last 3 months) steroid use, adenotonsillectomy in last 3 months, return visit to the ED but not previously enrolled, suspected peritonsillar abscess, unavailability for follow up and those requiring admission excluded. 10mg IM Dexamethasone vs. 10mg PO Dexamethasone vs. saline placebo. All patients were given antibiotics.	Randomized, double blind, placebo controlled trial	Decrease in 10cm pain visual analogue score at 12 hours	4.2±2.3 in IM Dexamethasone group vs. 3.8±2.3 in PO Dexamethasone group vs. 2.1±2.0 in placebo group. P<0.001	Not an Intention to Treat Analysis. No Power Calculation given.
			Percentage with complete resolution of pain within 12 hours	7±18.9 in IM Dexamethasone group vs. 8±20.0 in PO Dexamethasone group vs. 1±2.9 in placebo group. P=0.052
			Percentage returning to normal activity at 12 hours	25±67.6 in IM Dexamethasone group vs. 26±66.7 in PO Dexamethasone group vs. 12±35.3 in placebo group. P=0.001
			Percentage able to take liquids and solids at 12 hours	36±97.3 in IM Dexamethasone group vs. 40±100.0 in PO Dexamethasone group vs. 31±91.2 in placebo group. P=0.071
			Decrease in 10cm pain visual analogue score at 24 hours	5.0±2.4 in IM Dexamethasone group vs. 4.6±1.9 in PO Dexamethasone group vs. 3.6±2.6 in placebo group. P<0.097
			Percentage with complete resolution of pain within 24 hours	13±33.3 in IM Dexamethasone group vs. 12±29.3 in PO Dexamethasone group vs. 4±11.1 in placebo group. P<0.057
			Percentage returning to normal activity at 24 hours	33±84.6 in IM Dexamethasone group vs. 29±70.7 in PO Dexamethasone group vs. 20±55.6 in placebo group. P<0.018
			Percentage able to take liquids and solids at 24 hours	38±97.4 in IM Dexamethasone group vs. 40±97.6 in PO Dexamethasone group vs. 33±91.7 in placebo group. P>0.05

Comment(s)

All pertinent studies involve simultaneous prescription of empirical antibiotics for coverage of Streptococcal infection.

Clinical Bottom Line

A single dose of Dexamethasone or Betamethasone appears to reduce symptom severity in undifferentiated acute pharyngitis. Both IM and PO administration of Dexamethasone appears to be equally effective.

References

1. O'Brien JF. Meade JL. Falk JL. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Annals of Emergency Medicine Feb 1993. 22(2);212-215.
2. Marvez-Valls EG. Ernst AA. Gray J. Johnson WD. The role of betamethasone in the treatment of acute exudative pharyngitis. Academic Emergency Medicine June 1998 5(6);567-572.
3. Wei JL. Kasperbauer JL. Weaver AL. Boggust AJ. Efficacy of single-dose dexamethasone as adjuvant therapy for acute pharyngitis. The Laryngoscope January 2002 112(1);87-93.