First-Line Medication for Sore Throat in Adults
Either ibuprofen or paracetamol (acetaminophen) are the recommended first-line medications for acute sore throat in adults, with ibuprofen showing slightly superior pain relief efficacy. 1, 2
Primary Treatment Approach
Systemic analgesics should be the foundation of sore throat management, as most cases are viral in origin and do not require antibiotics. 1, 2
Preferred Analgesic Options
Ibuprofen is the preferred first-line systemic analgesic for acute pharyngitis, demonstrating slightly better efficacy than paracetamol, particularly after 2 hours of administration. 1, 2, 3
Paracetamol (acetaminophen) serves as an effective alternative when ibuprofen is contraindicated or not tolerated. 1, 2
Both medications demonstrate comparable safety profiles when used according to usual contraindications for short-term treatment of sore throat pain. 1, 2
Evidence Quality
The recommendation for ibuprofen and paracetamol is based on high-quality evidence (A-1 level), including systematic reviews and multiple randomized controlled trials showing superiority over placebo for reducing acute sore throat symptoms. 1
When Antibiotics Are NOT Indicated
Antibiotics should NOT be used in most cases of acute sore throat. The following situations do not warrant antibiotic therapy:
Patients with 0-2 Centor criteria (less severe presentations) should not receive antibiotics for symptom relief. 1, 2
Antibiotics are not indicated to prevent rheumatic fever or acute glomerulonephritis in low-risk patients without previous history of rheumatic fever. 1
Prevention of suppurative complications (quinsy, acute otitis media, cervical lymphadenitis, mastoiditis, acute sinusitis) is not a specific indication for antibiotic therapy. 1
When to Consider Antibiotics
For patients with severe presentations (3-4 Centor criteria), physicians should discuss the modest benefits of antibiotics (1-2 days symptom reduction) against potential harms:
- Side effects of antibiotics 1
- Impact on microbiota 1, 2
- Increased antibacterial resistance 1
- Medicalization and costs 1
If antibiotics are indicated, penicillin V twice or three times daily for 10 days is the recommended first choice. 1, 2
Adjunctive Therapies to Avoid
Several treatments should NOT be routinely recommended:
Local antibiotics or antiseptics lack efficacy data and should not be used given the predominantly viral etiology. 2, 4
Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects. 2, 4
Herbal treatments and acupuncture have inconsistent evidence and lack reliable efficacy data. 1, 2, 4
Corticosteroid Considerations
Corticosteroids are NOT routinely recommended for sore throat treatment. 1, 2, 5
However, in adult patients with severe presentations (3-4 Centor criteria), a single dose of corticosteroids can be considered in conjunction with antibiotic therapy. 1, 2, 5 This recommendation is based on evidence showing modest benefits in highly selected populations, though the effect may be considerably smaller in typical primary care settings. 5
Clinical Pitfalls
Avoid overuse of antibiotics: Research shows that 73% of adult sore throat visits result in antibiotic prescriptions, with 68% receiving non-recommended broad-spectrum antibiotics—a practice inconsistent with guidelines. 6
Do not use amoxicillin as first choice in older children/adults due to risk of severe rash in patients with Epstein-Barr virus infection. 1
Clinical scoring systems (Centor criteria) and rapid antigen tests can help target appropriate antibiotic use when testing is performed. 1