What is the management for sore throat and throat pain?

Management of Sore Throat and Throat Pain

Either ibuprofen or paracetamol (acetaminophen) should be used as first-line treatment for acute sore throat, with ibuprofen being slightly more effective for pain relief. 1, 2

First-Line Analgesic Therapy

• Ibuprofen is the preferred systemic analgesic if no contraindications exist, as it demonstrates superior efficacy compared to paracetamol, particularly after 2 hours of administration 2, 3
• Paracetamol serves as an effective alternative when ibuprofen is contraindicated 1, 2
• Both medications are safe when used according to directions for short-term treatment, with low risk of adverse effects 2
• Ibuprofen provides longer duration of action (6-8 hours) compared to paracetamol (4 hours), allowing less frequent dosing 4
• In comparative trials, ibuprofen reduced throat pain by 59% more than placebo over 24 hours, while also reducing difficulty swallowing by 45% and throat swelling by 44% 5

Antibiotic Decision Algorithm

Most patients with sore throat should NOT receive antibiotics. The decision depends on clinical severity using Centor criteria:

Patients with 0-2 Centor Criteria (Low Severity)

• Do not prescribe antibiotics for symptom relief 1
• These patients should be managed with analgesics alone 1
• Antibiotics provide no meaningful benefit in this population 1

Patients with 3-4 Centor Criteria (High Severity)

• Consider discussing modest benefits of antibiotics with patients, weighing against side effects, antibiotic resistance, and costs 1
• If antibiotics are indicated, prescribe penicillin V twice or three times daily for 10 days 1, 2
• Rapid antigen testing can help target antibiotic use in this population 1

Important Antibiotic Stewardship Points

• Antibiotics should NOT be used to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history) 1
• Prevention of suppurative complications (quinsy, otitis media) is not a specific indication for antibiotics, as the number needed to treat is 50-200 1
• The absolute risk of serious complications is extremely small in modern Western settings 1

Adjunctive Therapies

Corticosteroids

• Not routinely recommended for sore throat treatment 1
• May be considered in conjunction with antibiotic therapy for adults with severe presentations (3-4 Centor criteria) 1, 2
• The effect is smaller when administered orally and may be considerably less effective in typical primary care populations 1

Topical Treatments

• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can provide additional symptom relief 6
• Do NOT use local antibiotics or antiseptics due to the predominantly viral origin of sore throats and lack of efficacy data 2, 7, 8, 6

Not Recommended Treatments

• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects 1, 2, 7
• Herbal treatments and acupuncture lack reliable efficacy data and should not be recommended 1, 2, 7

Common Pitfalls to Avoid

• Do not assume patients have already tried paracetamol before consulting - many patients do not self-manage with analgesics, and GPs often wrongly assume they have 9
• Educate patients on proper analgesic dosing - patients who do use paracetamol often don't know how to use it effectively, leading to perceived treatment failure 9
• Do not prescribe antibiotics empirically without testing in patients with 3-4 Centor criteria - this drives antimicrobial resistance without proven benefit 8
• Explain treatment rationale thoroughly - patients generally accept recommended treatment when given proper explanation, as they trust their physician's expertise 9

Special Populations

Pediatric Patients

• Both ibuprofen and paracetamol are effective for sore throat symptoms in children 2, 7
• No significant difference in analgesic efficacy or safety between the two medications in pediatric populations 2, 7
• Ibuprofen has comparable safety profile to paracetamol when used appropriately, but paracetamol overdose is more severe and difficult to manage 4