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
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
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.
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 🙂