Steroids Are Not Appropriate for Routine Treatment of Upper Respiratory Infections
Steroids should not be routinely prescribed for upper respiratory tract infections (URIs) in adults or children, as there is no evidence of benefit and significant potential for harm. 1, 2
General Principle: Avoid Routine Steroid Use
Clinicians should not routinely prescribe corticosteroids to treat hoarseness, acute laryngitis, or uncomplicated URIs due to the overwhelming lack of supporting efficacy data and the potential for significant adverse effects including muscle weakness, neuropathy, and metabolic complications. 1
The American Academy of Pediatrics recommends against routine steroid treatment for URIs in children, as randomized controlled trials have not demonstrated differences in important clinical outcomes. 2
A large US cohort study found that 11.8% of patients with acute respiratory tract infections received systemic steroids despite lack of evidence supporting this practice, representing widespread inappropriate prescribing. 3
When Steroids May Be Considered (Limited Exceptions)
1. Croup in Children
- Pediatric patients with croup and associated hoarseness had better outcomes when treated with systemic steroids. 1
2. Allergic Laryngitis in Voice Performers
- In limited cases, systemic steroids have provided quick relief from allergic laryngitis for performers who are acutely dependent on their voice, though these are not high-quality trials. 1
- Intranasal corticosteroids may be used as adjunctive treatment, especially in patients with a history of allergic rhinitis. 4
3. Asthma Exacerbations Triggered by URI
- Inhaled budesonide started early after URI onset can attenuate exacerbation of URI-induced asthma, with significantly higher peak expiratory flow compared to placebo. 5
- This applies specifically to patients with known asthma, not to uncomplicated URIs. 2
4. NOT for Nephrotic Syndrome Relapse Prevention
- For children with frequently relapsing or steroid-dependent nephrotic syndrome, daily glucocorticoids should NOT be routinely given during URI episodes to reduce relapse risk. 1, 2
- The PREDNOS2 trial demonstrated no difference in URI-associated relapses between prednisolone and placebo over 12 months. 6
Key Evidence Against Routine Use
No randomized controlled trials support empiric steroid therapy for hoarseness or acute laryngitis except in the special circumstances noted above. 1
Acute laryngitis is self-limited, with improvement in 7-10 days with placebo treatment alone. 1
Short courses of systemic steroids in patients hospitalized with RSV infection did not affect viral load or shedding duration, though humoral immunity may be mildly diminished. 7
Common Pitfalls to Avoid
Do not prescribe steroids based on the assumption that URI-related inflammation requires anti-inflammatory treatment - the pathophysiology differs from conditions where steroids are proven effective. 2
Avoid the temptation to prescribe inhaled steroids for acute or chronic hoarseness or laryngitis due to potential for serious side effects, and paradoxically, long-term inhaled steroid use itself can cause hoarseness. 1
Geographic variation in prescribing is enormous (14-fold difference between US regions), suggesting practice is driven by habit rather than evidence. 3
Appropriate URI Management Instead
Focus on assessing hydration status, providing supplemental oxygen if SpO2 consistently below 90%, and monitoring for signs of respiratory distress. 2
Physiological saline nasal irrigation can be used as adjunctive treatment for acute bacterial sinusitis in adults. 2, 4
URIs are primarily clinical diagnoses that do not require diagnostic testing or steroid treatment. 2