What is the recommended prednisone (corticosteroid) course for a severe sore throat?

Prednisone Course for Severe Sore Throat

For adults with severe sore throat (Centor score 3-4), administer a single oral dose of dexamethasone 10 mg (or equivalent corticosteroid) in conjunction with appropriate antibiotic therapy. 1

Patient Selection Criteria

Use corticosteroids only in adults with severe presentations, defined as Centor score 3-4 points (one point each for: tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough, and fever >38°C). 2, 1

• Do not use corticosteroids routinely for all sore throat cases 2, 3
• Do not use in children - no significant benefit has been demonstrated in pediatric populations 2, 1
• Exclude patients with diabetes, glucose dysregulation, those already on exogenous steroids, or endocrine disorders 1

Dosing Regimen

Single-dose therapy is the recommended approach:

• Dexamethasone 10 mg orally once (based on corticosteroid equivalency where dexamethasone is 25 times more potent than hydrocortisone) 1
• Alternative: Prednisone 60 mg orally once 4
• Do not extend beyond a single dose 1

The single-dose approach provides adequate anti-inflammatory effect without requiring weight-based calculations in adults. 1

Expected Clinical Benefits

Corticosteroids provide modest but measurable symptom improvement:

• 2.4 times increased likelihood of complete pain resolution at 24 hours (Number Needed to Treat = 5) 5
• 1.5 times increased likelihood of complete pain resolution at 48 hours 5
• Mean reduction in time to pain relief: 6 hours 5
• Mean reduction in time to complete pain resolution: 11.6 hours 5
• Additional 10.6% reduction in pain scores at 24 hours 5

Concurrent Treatment Requirements

Always combine corticosteroids with:

• Appropriate antibiotic therapy (penicillin V for 5-10 days as first-line if Centor ≥3) 2, 1
• Ibuprofen or acetaminophen for symptomatic relief - this is first-line adjunctive therapy with strong evidence 2, 3

Critical Safety Considerations

Important caveats about corticosteroid use:

• The Infectious Diseases Society of America explicitly recommends against corticosteroids as adjunctive therapy for Group A Streptococcal pharyngitis (weak recommendation, moderate quality evidence) 3
• Short- and long-term steroid risks include hypertension, cardiovascular disease, osteoporosis, impaired wound healing, infections, mood disorders, and diabetes 3
• Studies were not sufficiently powered to detect adverse effects of short courses 2, 1
• The effect is considerably smaller in typical primary care populations where most patients do not have severe sore throat 1
• Oral administration appears less effective than other routes 1

Shared Decision-Making

Discuss with patients:

• The modest benefit (approximately 5 hours reduction in pain duration) 3
• Potential adverse effects, even from single-dose therapy 2, 3
• That ibuprofen or acetaminophen alone may be preferable as first-line therapy given the strong recommendation and high-quality evidence for NSAIDs 3

When NOT to Use Corticosteroids

Avoid corticosteroids in:

• Centor score 0-2 (low to moderate risk) 2, 1
• Children of any age 2, 1
• Patients with contraindications to steroids 1
• Hoarseness or dysphonia without proper evaluation (preponderance of harm over benefit) 1
• As routine treatment for all sore throat presentations 2, 3