Key messages

• Systemic corticosteroids decrease pain related to acute pharyngitis.
• There are minimal or no adverse effects associated to a short course of corticosteroids.

What is the evidence.
See evidence matrix  in Epistemonikos later

We identified eight systematic reviews [1],[2],[3],[4],[5],[6],[7],[8], including 11 primary studies [9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19], of which 10 corresponded to randomized trials [9],[10],[12],[13],[14],[15],[16],[17],[18],[19]. This table and the summary in general are based on the latter.

What types of patients were included*

All of the trials considered patients presenting with acute pharyngitis.

Six trials only included adult patients [9],[12],[13],[14],[18],[19], three only pediatric patients [10],[15],[17] and one did not differentiate [16]. Average age was 24 years, including patients from four years and older.

Detection of group A beta-hemolytic Streptococcus was an inclusion criterion in one trial [15]. Two trials did not report detection of this pathogen [16],[18]. The remaining trials reported detection in 14.9 to 57.5% of patients [9],[10],[12],[13],[14],[17],[19].

Among exclusion criteria the following stand out: previous use of antibiotics in two trials [10],[12], pregnancy in nine trials [10],[12],[13],[14],[15],[16],[17],[18] and diabetes mellitus in nine trials [9],[10],[12],[13],[14],[16],[18],[19]. 

All trials excluded immunocompromised patients, suspected peritonsillar or retropharyngeal abscess and previous use of corticosteroids.

Three trials were conducted in primary care [10],[12],[13], while the remaining trials were conducted in emergency departments [9],[14],[15],[16],[17],[18],[19].

What types of interventions were included*

All of the trials compared systemic corticosteroids against placebo or no treatment.

Most trials used a single 8-10 mg or 0.6 mg/kg dose of dexamethasone [9],[10],[12],[15],[16],[17],[18],[19]. One trial used prednisone [13] and one used betamethasone [14], both as single dose.

Route of administration was oral in seven trials [9],[10],[12],[13],[15],[17],[19] and intramuscular in three [14],[16],[18].

In six trials, all patients received antibiotics [9],[14],[15],[16],[18],[19]. In four trials, the indication of antibiotics was at physician discretion or when group A beta-hemolytic Streptococcus was detected [10],[12],[13],[17].

In four trials, all patients received analgesia [9],[15],[18],[19] and in the remaining trials analgesia was at physician discretion [10],[12],[13],[14],[16],[17].

What types of outcomes
were measured

Systematic reviews grouped outcomes as follows: resolution of pain at 24 or 48 hours, time to onset of pain relief, time to complete resolution of pain, pain intensity (visual analog scale) at 24 hours, symptoms recurrence, antibiotic prescription, work and school absentism, and adverse effects.

Mean follow up time in trials was 18 days, with a range from three days to two months.

To whom this evidence does and does not apply

• The present summary applies to children and adults with acute pharyngitis in primary care or emergency department setting.
• Some trials demanded detection of group A beta-hemolytic Streptococcus or reported a high percentage of detection, however this was not predominant, therefore results apply regardless of the etiology of acute pharyngitis.
• Even though most analysed trials prescribed antibiotics, results can be extrapolated to patients without indication of antibiotics. In fact, the trial that included the highest amount of patients did not initially prescribed them [12].
• The present summary does not apply to immunocompromised patients or those with suspected peritonsillar or retropharyngeal abscess. Pregnant patients or those with diabetes mellitus were excluded from the analysed trials, and the use of corticosteroids could imply other consequences for them.

• To generate the summary of findings table we selected outcome resolution of pain at 24 hours, because it was considered critical for decision-making. This selection is based on the opinion of the authors of this article.
• Effects over other outcomes related to pain do not modify conclusions: resolution of pain at 48 hours (164 more per 1000 patients [95% CI: 88 to 249 more]; certainty of evidence: moderate) [12],[13],[15],[18], time to onset of pain relief (MD -4.84 hours [95% CI: -1.9 to -7.8]) [9],[10],[12],[14],[16],[17],[18],[19], time to complete resolution of pain (MD -11.1 hours [95% CI: -0.41 to -21.8]) [10],[12],[14],[16],[17],[18].

• The present summary shows a reduction of pain when systemic corticosteroids are added to the treatment of acute pharyngitis, with high certainty.
• The use of corticosteroids in this context does not increase the risk of adverse effects.
• Severe adverse effects (peritonsillar abscess, pneumonia) did not vary between intervention and placebo either [8]. It should be noted that observational studies have reported severe adverse effects with short periods of corticosteroids in adult patients, therefore their low frequency ocurrence cannot be discarded [20]. A systematic review on the use of short periods of corticosteroids in children presenting with respiratory conditions did not show an increase in adverse effects [21].
• The balance between benefits and risk for this intervention is favorable.

• Systemic corticosteroids for short periods have a low cost.
• If benefits, absence of adverse effects and low cost are considered, this intervention is probably cost-effective. A formal economic analysis might allow quantification of cost-benefit of this intervention in specific settings.

• Facing the evidence presented in this summary, most patients and caregivers should incline towards its use.
• However, some patients might choose no treatment, as this condition is self-limited.

Differences between this summary and other sources

• The conclusion presented in this summary agree with systematic reviews identified.
• The conclusions from this summary are partially concordant with the main guidelines. The 2012 ad-hoc guideline of the European Society of Clinical Microbiology and Infectious Diseases recommends the use of systemic corticosteroids only for adult patients with severe presentation of acute pharyngtis, added to concomitant antibiotic use [22]. The 2012 guideline from the Infectious Diseases Society of America (IDSA) does not recommend the use of systemic corticosteroids for acute pharyngitis caused by group A beta-hemolytic Streptococcus [23]. It is important to highlight that the recommendation from this guidelines is based on a portion of the evidence identified in this summary.

• Given the certainty of evidence, there is a very low probability of future investigation changing this conclusion.
• We did not identify ongoing trials in the International Clinical Trials Registry Platform of the  World Health Organization evaluating the use of systemic corticosteroids for acute pharyngitis.