Critically Appraised Topic: Dexamethasone for Sore Throat?

Fri, 12/18/2020 - 9:39am
Author: 
Christine Collins, MD
Editor: 
John Cafaro MD
Clinical Question: Does dexamethasone shorten the duration of pain in patients with sore throat?
This review examines 2 studies(Hayward et al, Wei et al.) that studied this topic.
Study #1(Howard et al.): This is a double blind, placebo-controlled randomized trial conducted at family medicine practices in England(n=565) w/ a goal to assess the effectiveness of oral dexamethasone for sore throat without the use of antibiotic therapy. Medications were pre-randomized into packs, one with 10 mg of oral dexamethasone and another with lactose(placebo). Rapid strep antigen tests were not available to clinicians. Clinicians could choose whether to offer no antibiotics at all or delayed antibiotics(48 hours after presentation). The primary outcome was complete resolution of sore throat at 24 hours relayed by text message or telephone contact by patient.  For the primary outcome, there was no statistically significant difference between complete resolution of sore throat at 24 hours(RR 1.28, risk difference 4.7%, 95% CI-1.8% to 11.2%). There was a significant difference at 48 hours(RR 1.31, risk difference 8.7%, 95% CI 1.2% to 16.2%). Authors concluded that a single dose of oral dexamethasone was not found to increase resolution of symptoms of sore throat at 24 hours, but there was a significant difference at 48 hrs.
Strengths:  Randomized, double-blinded with well balanced treatment groups. Participant adherence w/ medication was measured at 100%, and the primary outcome measure was collected from 93.6% of patients. They exceeded their goal enrollment. 
Limitations: Only 5 patients reported series outcomes. 2 in the dexamethasone group, and 3 in placebo group. Insufficient data to address adverse events.
 
Study #2(Wei et al): This is a double blind, placebo-controlled study(n=118) at an ED in which patients were given a single IM dose of dexamethasone vs. 10 mg oral dexamethasone vs. placebo. Each patient received both a pill and an IM injection, with the ED physician and patient blinded to the treatment. Each patient was empirically treated with a 10 day course of 500 mg PCN or erythromycin(if PCN allergy). Patients rated their subjective pain using visual analog scales at 12 and 24 hours as well as report time of initial pain relief as well as time to complete resolution of pain. At 12 hours, the change in pain scores was significantly greater in patients with received IM dexamethasone(mean score 4.2 ±2.3) and PO dexamethasone(mean score 3.8±2.3) compared to placebo(mean score 2.1 ±2.0).  Patients who were given dexamethasone had a median 4 hours earlier resolution of symptoms than those given placebo. Patients were followed for 5 days, and only 9 patients sought further care for their sore throat(3 receiving PO dexamethasone and 6 receiving placebo. 
Strengths: Randomized, double-blinded with well balanced treatment groups.  In comparison to Study 1 had more exclusion criteria to control for confounding variables.
Limitations: There was no calculation to address needed sample size to meet goal enrollment. Insufficient data to address adverse events. 
*Both studies were limited in that they relied on the patient's subjective pain scores/follow up through the telephone/text which can vary from patient to patient. 
 
Conclusions: 
  • There is evidence that suggests dexamethasone decreases the duration of pain in both patients who receive antibiotics and those who don’t(received delayed antibiotics).
  • This evidence is based on patients with uncomplicated sore throat. 
  • There is little/poor evidence on the risks of dexamethasone use for sore throat to do a risks/benefits analysis 
 
References: 
  1. Hayward GN, Hay AD, Moore MV, et al. Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA. 2017;317(15):1535–1543. doi:10.1001/jama.2017.3417
  2. Wei, J.L., Kasperbauer, J.L., Weaver, A.L. and Boggust, A.J.(2002), Efficacy of Single‐Dose Dexamethasone as Adjuvant Therapy for Acute Pharyngitis. The Laryngoscope, 112: 87-93. https://doi.org/10.1097/00005537-200201000-00016