What is the pharmacological management for sore throat?

Pharmacological Management for Sore Throat

First-Line Treatment: Analgesics

Either ibuprofen or paracetamol (acetaminophen) are recommended as first-line pharmacological treatments for acute sore throat, with ibuprofen showing slightly superior efficacy for pain relief, particularly after 2 hours of administration. 1, 2

Analgesic Selection and Dosing

• Ibuprofen is the preferred first-line systemic analgesic when no contraindications exist, as it demonstrates better efficacy than paracetamol for pain relief across all time points after 2 hours 1, 2, 3
• Paracetamol serves as an effective alternative with equivalent safety profile for short-term treatment 1, 2
• Both medications are safe when used according to usual contraindications and directions 2, 4
• In children, both ibuprofen and paracetamol show no significant difference in analgesic efficacy or safety 1, 2, 4

Topical NSAIDs

• Flurbiprofen 8.75 mg lozenges can be considered as adjunctive therapy for patients with swollen and inflamed throat, providing relief of sore throat pain, difficulty swallowing, and throat swelling (up to 5 lozenges per 24 hours, every 3-6 hours as needed) 5

Corticosteroid Therapy: Risk-Stratified Approach

Corticosteroids are NOT routinely recommended for sore throat treatment but can be considered in adult patients with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy. 1, 2, 6

When to Consider Corticosteroids

• Only for adults with 3-4 Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 2, 6
• Single oral dose of dexamethasone 10 mg is the recommended regimen when indicated 6
• Must be used in conjunction with appropriate antibiotic therapy 1, 6
• Do NOT use for patients with 0-2 Centor criteria 6

Contraindications to Corticosteroids

• Diabetes mellitus or glucose dysregulation 6
• Patients already on exogenous steroids 6
• Endocrine disorders 6

Antibiotic Therapy: Selective Use Only

Antibiotics should NOT be used in patients with less severe presentations (0-2 Centor criteria) to relieve symptoms, as they provide minimal benefit and contribute to antimicrobial resistance. 1, 2

Risk-Stratified Antibiotic Decision Algorithm

• Centor score 0-1: No antibiotics indicated, no bacteriological testing needed 7
• Centor score 2: Consider bacteriological testing (rapid antigen test or culture); treat only if positive 7
• Centor score 3-4: Bacteriological testing recommended; discuss modest benefits versus risks (side effects, microbiota disruption, resistance, medicalization, costs) with patient 1, 2

Antibiotic Selection When Indicated

• Penicillin V is the first-choice antibiotic when treatment is indicated, dosed twice or three times daily for 10 days 1, 2, 8
• Clarithromycin serves as an alternative for penicillin-allergic patients 8, 7
• There is insufficient evidence supporting shorter treatment durations 1

Key Antibiotic Limitations

• Do NOT prescribe antibiotics to prevent rheumatic fever or acute glomerulonephritis in low-risk patients (those without previous rheumatic fever history), as absolute risk is extremely small in modern Western populations 1
• Prevention of suppurative complications (quinsy, otitis media, sinusitis) is NOT a specific indication for antibiotic therapy, with number needed to treat ranging from 50-200 1
• Antibiotics provide only modest symptom reduction on day 3, with benefit primarily in Group A β-hemolytic streptococcus-positive patients 1

What NOT to Use

Ineffective or Not Recommended Treatments

• Zinc gluconate is NOT recommended for sore throat treatment due to conflicting efficacy results and increased adverse effects 1, 2, 4
• Local antibiotics or antiseptics should NOT be used due to predominantly viral etiology and lack of efficacy data 2, 4
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended (evidence quality C-1 to C-3) 1, 2, 4

Clinical Pitfalls to Avoid

• Avoid over-prescribing antibiotics for self-limited viral pharyngitis, which accounts for more than 65% of cases 8
• Do not use clinical scoring alone to justify antibiotics without considering the modest absolute benefit and potential harms 1
• Avoid routine corticosteroid use in typical primary care populations where most patients do not have severe presentations 6
• Do not prescribe antibiotics for symptom relief in low-risk patients, as duration of symptoms is only modestly shortened (mean duration 7 days regardless) 8