Can I use a short course of 20 mg per day steroid for 2 days in a patient with viral pharyngitis and a history of alcohol and smoking?

Steroids in Viral Pharyngitis with History of Alcohol and Smoking

Corticosteroids should not be used for viral pharyngitis, especially in patients with a history of alcohol and smoking, due to potential adverse effects and lack of proven benefit.

Evidence Against Steroid Use in Viral Pharyngitis

The 2018 clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery strongly recommend against prescribing corticosteroids for patients with dysphonia (which often accompanies pharyngitis) prior to visualization of the larynx 1. This recommendation is based on randomized trials showing adverse events and an absence of clinical trials demonstrating benefits.

Even short-term steroid use carries significant risks:

• Side effects can occur with both short and long-term use 1
• A short course of oral steroids for chronic rhinosinusitis has been associated with insomnia and gastrointestinal disturbances 1
• Documented side effects of short-term steroid therapy include:
  • Hypertension
  • Cardiovascular disease
  • Impaired wound healing
  • Infection risk
  • Mood disorders
  • Diabetogenesis 1

Risk Factors in Your Patient

Your patient's history of alcohol and smoking compounds these risks:

• Alcohol use can increase the risk of gastrointestinal side effects from steroids
• Smoking history increases baseline risk for respiratory infections
• Both factors may impair healing and immune response

Appropriate Management for Viral Pharyngitis

The Pharyngitis and Tonsillitis Management guidelines recommend:

1. Symptomatic treatment with analgesics as the primary approach for viral sore throat 2:

   • Ibuprofen: 400mg every 6-8 hours (maximum 1200mg/day)
   • Paracetamol: 500-1000mg every 4-6 hours (maximum 4000mg/day)

2. Maintain hydration - crucial for recovery 2

3. Avoid antibiotics - not effective for viral infections 2

When Steroids Might Be Considered (Not Applicable Here)

While a 2005 study suggested short-acting oral steroid therapy might shorten throat pain duration in acute pharyngitis 3, more recent guidelines and evidence do not support this practice. The 2024 Streptococcal Pharyngitis review explicitly states that "steroids are not recommended for symptomatic treatment" 4.

Additionally, a 2012 study highlighted potentially life-threatening complications of steroids in patients with pharyngitis who had undiagnosed malignancies 5, further supporting caution with steroid use.

Bottom Line

For viral pharyngitis in a patient with history of alcohol and smoking:

• Focus on symptomatic relief with appropriate analgesics
• Ensure adequate hydration
• Avoid both antibiotics and corticosteroids
• Consider antiseptic lozenges which have demonstrated bactericidal activity against common pharyngeal pathogens 6

The 2-day, 20mg course of steroids you're considering is not supported by current evidence and guidelines, and carries unnecessary risks, especially given your patient's history of alcohol and smoking.