post

A dose of Dex?

I have a confession.  For as long as I can remember I have been prescribing a dose of dexamethasone or two for people with acute tonsillo-pharyngitis.  Now, I always thought this was a little bit naughty, not really “the done thing” for a doc who tries to be evidence-based.  But over the years I have always found it to be quite effective.  Even tried it myself a few times!

Now to be clear – I am not using it for every sore throat I see.  I tend to use it in the sick, really nasty-looking, not drinking, might need admission sore throats.  Or sometimes in people who need to get well quickly – e.g. me.

Now the Cochrane folk have released a review of the evidence for steroids in acute tonsillitis or pharyngitis.  And guess what – it just might be an effective therapy.  Check out the full Cochrane review here.

If you are too busy to read that big document there was a quick chat on the ABC Health program: Norman Swan: ABC Health Report, in which Dr Swan interviews public health guru Professor Paul Glasziou.

In summary the RCTs showed:

– a benefit in terms of reduction in pain – a good patient-based outcome

– the benefit was pretty early i.e. 24 hours on average

– The same was seen in kids and adults

– no real difference between bacterial or viral pharyngitides – do we know which is which anyway?

– Unfortunately the studies all included antibiotics in addition to steroids  – so potentially confounded the data.

I think I will keep using a dose of Dex [dexamethasone] for the bad throats for now.  I think we need a solid head-to-head trail to compare steroids to placebo in patients who get no antibiotics.  Maybe a third arm for ibuprofen?  Would be a good study to read.

What say you?      Casey

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Comments

  1. Back in 2004…… http://bestbets.org/bets/bet.php?id=740 BBs looked at this and concluded that there was evidence back then. Looks like we need an update, but you have already got there.

    Interestingly we have not seen a take up of it in the UK (to my knowledge anyway), so your post is a great one to re-ignite the debate.

    Cheers Casey.

    S

    • We need a trial of naked steroids vs placebo. Shouldn’t be too hard?
      In the mean time I say to patients: if you want ABs then try this first. If not improving or worse follow up. Less ABs, less pain, patient empowered. Unlikely to get common side effects at low dose for 1-2 days
      C

  2. I’ve been doing this for about 3 or 4 years now -- as you say for the really miserable ones. Because of the nature of ED it’s hard to know how much success I’ve got from it but I view it as a cheap and easy and fairly benign intervention. Sore throat is all about symptomatic management and it’s another arrow in the quiver.

  3. Emma Griffiths says:

    I used this in a difficult patient on the third presentation for what seemed consistent with viral pharyngitis (without antibiotics) and he rang up to thank me for the magic pills :)

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