A study has suggested short-term steroids rather than antibiotics as the first-line response for severe sore throats
With GPs under pressure to stop prescribing antibiotics unnecessarily, the hunt is on for a medicine to fill the prescription void in patients desperate to alleviate symptoms, says Chris Del Mar, a professor of public health at Bond University.
One likely candidate is corticosteroids for severe, acute sore throats, which have already been shown in a Cochrane review1 to accelerate the resolution of symptoms when taken in combination with antibiotics.
Now, a randomised study of more than 560 adults2 has investigated whether a single 10mg dose of oral dexamethasone taken without antibiotics could help relieve acute sore throat symptoms.
At 24 hours, there was no difference between the dexamethasone and placebo groups.
But, importantly, dexamethasone significantly improved symptoms after 48 hours when compared with placebo.
The effect of dexamethasone was small but significant, with symptoms resolving in 35% of patients in the dexamethasone group and 27% of patient in the placebo group after 48 hours (a difference of 8%).
Around 40% of study participants were given a delayed prescription for antibiotics to use if symptoms did not improve within 48 hours.
“This trial is interesting as we watch with horror as the shadow of the post-antibiotic era of medicine falls across the world,” said Professor Del Mar.
Antibiotics were still widely used in general practice for acute respiratory infections, he said. But the health benefits were tiny.
“We could probably reduce our prescribing enormously with no discernible adverse effects on the health of our patients.”
However, GPs faced a “therapeutic vacuum” if they stopped prescribing antibiotics. “What can we offer our patients if not antibiotics?” Professor Del Mar asked.
Over-the-counter analgesics have a modest effect and there is some data showing that NSAIDs reduce the pain of sore throats quite quickly.
While some emergency physicians in hospitals prescribed steroids in combination with antibiotics, GPs generally did not prescribe dexamethasone for sore throats, Professor Del Mar said.
However, if a patient experienced severe symptoms, GPs might consider prescribing dexamethasone alone or in combination with antibiotics if they believed it to be bacterial.
In most cases, symptoms are less severe and will resolve without treatment.
“I would probably not prescribe anything … except in exceptional circumstances,” Professor Del Mar said.
“If there is a history of acute rheumatic fever … then I would use penicillin for 10 days. But just for symptom relief, antibiotics are not that great.”
Short-term steroids had a reasonable safety profile, “although there has been some concern recently that people who are given steroids, even a short course like this, might be at risk from getting an infection problem later”.
Other downsides to taking steroids include difficulty sleeping, acid reflux and increased appetite.
Professor Del Mar has worked with the research group that produced this study in the past.