Corticosteroids added to antibiotic for sore throats

[Lynn Cremona]

Just in case you thought antibiotics were enough of a problem:
From Medscape Medical News
Corticosteroids May Help Relieve Pain of Sore Throat
Laurie Barclay, MD
August 17, 2009 — Corticosteroids may help relieve sore throat pain when
added to antibiotics in patients with severe or exudative sore throat,
according to the results of a systematic review and meta-analysis
reported in the August 7 Online First issue of the /BMJ/

"The pressure for clinicians to reduce antibiotic prescriptions for sore
throat leaves a therapeutic vacuum," write Gail Hayward, University of
Oxford, Oxford, United Kingdom, and colleagues. "Corticosteroids inhibit
transcription of proinflammatory mediators in human airway endothelial
cells which cause pharyngeal inflammation and ultimately symptoms of
pain. Corticosteroids are beneficial in other upper respiratory tract
infections such as acute sinusitis, croup, and infectious mononucleosis."

To determine whether systemic corticosteroids appear to relieve symptoms
of sore throat in adults and children, the reviewers searched Cochrane
Central, Medline, Embase, Database of Reviews of Effectiveness, NHS
Health Economics Database, and reference lists of retrieved articles.
Pertinent endpoints included percentage of patients with complete
resolution of sore throat at 24 and 48 hours, mean time to onset of pain
relief, mean time to complete resolution of symptoms, days absent from
work or school, recurrence of sore throat, and adverse events.

The reviewers identified 8 relevant trials enrolling a total of 743
patients, including 369 children and 374 adults. Exudative sore throat
was present in 348 (47%) of these patients, and 330 (44%) tested
positive for group A β-hemolytic streptococcus.

Four trials showed that when added to antibiotics and analgesia,
corticosteroids were associated with significant, marked improvement in
the likelihood of complete pain resolution at 24 hours (relative risk
[RR], 3.2; 95% confidence interval [CI], 2.0 - 5.1). Three trials showed
similar but less dramatic results at 48 hours (RR, 1.7; 95% CI 1.3 - 2.1).

In 6 trials, corticosteroids were associated with decrease by more than
6 hours in mean time to onset of pain relief (95% CI, 3.4 - 9.3; /P/ <
.001). However, there was significant heterogeneity in these trials, and
the mean time to complete resolution was inconsistent across trials,
precluding pooled analysis. For other outcomes, reporting was limited.

"Corticosteroids provide symptomatic relief of pain in sore throat, in
addition to antibiotic therapy, mainly in participants with severe or
exudative sore throat," the study authors write.

Limitations of this study include inadequate reporting for some
outcomes, recall bias, inability to assess publication bias, and
significant heterogeneity in some analyses. An important limitation was
use of antibiotics in both corticosteroid and placebo groups, either to
all participants, or to all participants with group A β-hemolytic
streptococcus culture result or a positive result on rapid antigen test.

"Our findings suggest that in patients with severe or exudative sore
throat, pain can be reduced and resolution hastened by use of
corticosteroids in conjunction with antibiotic therapy," the study
authors conclude. "Our research suggests that patients with severe or
high Centor scoring sore throat would benefit from a single dose of
corticosteroids. The use of corticosteroids will triple the likelihood
of resolution at 24 hours and hasten this resolution by more than 6
hours, even in patients who have also been given antibiotics and
analgesics."

In an accompanying editorial, Paul Little, from the University of
Southampton in Southampton, United Kingdom, notes that the complications
of steroids cannot be investigated in a meta-analysis of this size.

"Clearly more research is needed, particularly more robust evidence for
the use of oral steroids in more typical populations and in patients not
receiving antibiotics; better data are also needed about the likely
incidence of rare complications in primary care," Dr. Little writes. "In
the meantime, what should clinicians advise their patients given these
uncertainties? Clinicians should outline the evidence for the efficacy
of steroids in terms of pain control during the first 24 hours (in terms
of how rapidly the placebo groups settle and the additional benefit from
steroids), convey the slight uncertainty about rare side effects, and
then let the patient decide."

/The British Society for Antimicrobial Chemotherapy Systematic Review
funded this work in part. The review authors and Dr. Little have
disclosed no relevant financial relationships./

/BMJ/. Published online August 7, 2009. Abstract

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