Antibiotics are prescribed in 60% of UK primary care sore throat consultations, a trend that shows no sign of decreasing. In the face of mounting pressure to reduce antibiotic prescribing, what alternatives are there for treating the one-in-ten people who visit their doctor each year with this common ailment?
As both a GP and an academic researcher, I see a lot of patients who are suffering with sore throats, and I know that effective alternative treatments to antibiotics would be welcomed by both GPs and patients. While previous research on the subject has suggested a role for corticosteroids, the evidence is yet to be compelling enough to herald a step-change in our approach to acute sore throat.
So along with researchers from the Universities of Oxford, Bristol and Southampton, we set out to shed some light on the issue by examining, for the first time, the effect of a single corticosteroid capsule given to patients in primary care who present with a sore throat.
Working closely with general practices across the South and West of England, Oxford University’s Primary Care Clinical Trials Unit (in partnership with trials units in Southampton and Bristol) recruited 565 adults who came to see their GP with sore throat, but were not so unwell they needed immediate antibiotics. The patients were assigned randomly to either take a corticosteroid (10mg of dexamethasone) or a placebo – and the GP was instructed to only prescribe ‘delayed’ antibiotics (for the patient to take just in case their symptoms didn’t ease up after a couple of days) if they felt this was clinically necessary.
We followed up by text message to find out whether patients were feeling completely better, how long they had moderately bad symptoms for, whether they had time off work, and if they had cashed-in the antibiotic prescription.
After 24 hours, corticosteroids had no effect on sore throat symptoms compared with the control group. Yet after 48 hours we did see a difference, though only a relatively small one – 35% of patients who had been prescribed a steroid felt better compared with 27% who didn’t receive a steroid. This means that on average a doctor would need to prescribe corticosteroids to 12 patients to help 1 additional patient feel better after 48 hours.
While this is an improvement, steroid treatment was not the silver bullet we had considered it might be – it didn’t reduce the amount of time patients had moderately bad symptoms, pain, difficulty swallowing or the amount of time they missed from work. It also didn’t reduce the number of patients who decided subsequently to cash in their antibiotic prescription.
So is this effect at 48 hours strong enough evidence to warrant a shift to GPs prescribing corticosteroids routinely for sore throat ? Let’s first consider some caveats – our study recruited patients with less severe sore throat on average since we couldn’t ask GPs not to treat those patients who were bad enough to need immediate antibiotics. We also excluded patients where steroids can be harmful – like those with diabetes and heart disease, and we didn’t include children in our study. So our data isn’t entirely representative, but it’s probably the best that’s currently available.
And then there are the side-effects of corticosteroids to consider – such as changes in mood and increased appetite in the short term, and weaker bones and high blood pressure after using steroids frequently for longer periods of time. If patients were taking steroid courses for other medical conditions at the same time as visiting their doctor with a sore throat, these longer-term side effects might start to become a concern. We also need to consider whether patients might seek GP appointments more frequently for sore throat if their GP were to prescribe steroids, which could reduce the amount of time GPs have to spend with patients with more serious medical conditions.
So balancing our findings with the potential harms of corticosteroids, and the general consensus that the majority of sore throats will get better on their own, the evidence to date doesn’t support the routine use of steroids for patients with sore throat in primary care. While corticosteroids may still play a role in other aspects of sore throat management due to their anti-inflammatory properties, such as for patients seen in hospital settings, or if a patient is unable to swallow or take other medications, GPs should continue to fall back on conventional wisdom for sore throat – over-the-counter painkillers, drinking plenty of fluids and time.
The TOAST Trial (Treatment Options without Antibiotics for Sore Throat) was funded by the National Institute for Health Research School for Primary Care Research (NIHR SPCR). The views expressed are those of the author and not necessarily those of the NIHR, the NHS or the Department of Health.
Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial
Hayward GN, Hay AD, Moore M et al
JAMA. 2017;317(15):1535-1543. doi:10.1001/jama.2017.3417
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