Prednisone Taper for Swollen Tonsils and Sore Throat
A prednisone taper is not appropriate for managing swollen tonsils and sore throat—instead, use a single dose of oral corticosteroid (such as dexamethasone 10 mg) only in adults with severe presentations (Centor score 3-4), alongside antibiotics and standard analgesics. 1
Why a Taper Is Not Recommended
Corticosteroids for sore throat should be given as a single dose, not a taper. The evidence supporting corticosteroid use in sore throat is based exclusively on single-dose administration, typically oral dexamethasone 10 mg or equivalent. 1, 2, 3
Multi-day tapers have not been adequately studied for safety in this indication, and existing trials were not sufficiently powered to detect adverse effects even from short courses. 1
The American College of Physicians specifically recommends considering corticosteroids only as a single dose in conjunction with antibiotic therapy for severe cases. 1
When to Consider a Single Dose of Corticosteroid
Severity assessment is critical:
Use corticosteroids only in adults with severe presentations, defined as Centor score 3-4 (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough). 1
In these severe cases, a single oral dose of dexamethasone 10 mg can be considered alongside appropriate antibiotic therapy. 1
Do not use corticosteroids routinely for all cases of sore throat—the effect is considerably smaller in typical primary care populations where most patients do not have severe presentations. 1
Expected Benefits
The benefits are modest but measurable:
Patients receiving a single dose of corticosteroids are 2.4 times more likely to experience complete pain resolution at 24 hours (number needed to treat = 5). 2, 3
Mean time to onset of pain relief is approximately 4.8 hours earlier, and complete resolution occurs about 11.6 hours earlier compared to placebo. 2
At 24 hours, pain scores are reduced by an additional 10.6% on visual analogue scales. 2, 3
At 48 hours, patients are 1.5 times more likely to have no pain. 2, 3
Contraindications to Avoid
Screen for these exclusion criteria before prescribing:
- Patients with diabetes mellitus or glucose dysregulation 1
- Patients already on exogenous steroids 1
- Patients with endocrine disorders 1
- Children (no significant benefit has been demonstrated in pediatric populations) 1
Standard Management Regardless of Steroid Decision
Always provide appropriate symptomatic treatment:
Recommend ibuprofen or paracetamol as first-line analgesics for pain relief. 1, 4
For patients with Centor score 3-4, discuss the modest benefits of antibiotics (1-2 days symptom reduction) against side effects, antimicrobial resistance, and costs. 5
Penicillin remains the first-choice antibiotic when bacterial treatment is indicated, due to proven efficacy, safety, narrow spectrum, and low cost. 5
Delayed antibiotic prescribing is a valid option for appropriate cases. 5
Common Pitfalls
Do not prescribe multi-day steroid tapers—this lacks evidence and may increase harm without additional benefit. 1, 2, 3
Do not use steroids in patients with low Centor scores (0-2)—antibiotics should not be used in these less severe presentations, and steroids offer minimal benefit. 5, 1
Do not prescribe steroids for hoarseness or dysphonia without proper evaluation—there is a preponderance of harm over benefit in these presentations. 1
Do not assume safety from short-term use—adverse effects may not have been adequately captured in existing studies. 1