What is the treatment for a sore throat?

Treatment of Sore Throat

For acute sore throat, start with ibuprofen or paracetamol (acetaminophen) as first-line therapy, with ibuprofen showing slightly superior pain relief, and reserve antibiotics only for patients with 3-4 Centor criteria after discussing the modest benefits against risks. 1

First-Line Symptomatic Treatment

Analgesics are the cornerstone of sore throat management:

• Ibuprofen 400-600 mg every 6-8 hours is the preferred first-line systemic analgesic, demonstrating slightly better efficacy than paracetamol particularly after 2 hours of administration 1, 2
• Paracetamol 500-1000 mg every 6 hours is an effective alternative, especially in patients with renal impairment where NSAIDs pose risks 1, 3
• Both medications are safe for short-term use with low risk of adverse effects 1
• Local anesthetics (lidocaine 8mg, benzocaine 8mg, or ambroxol 20mg) can be considered as adjuncts, with ambroxol having the best documented benefit-risk profile 4

Risk Stratification Using Centor Criteria

Use the Centor scoring system to guide antibiotic decisions (1 point each for: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough) 5, 1:

• 0-2 Centor criteria (low risk): Do NOT use antibiotics - they provide no benefit and contribute to resistance, side effects, and unnecessary medicalization 5, 1
• 3-4 Centor criteria (high risk): Consider antibiotics only after discussing modest benefits (1-2 days symptom reduction) versus risks with the patient 5, 1

Antibiotic Therapy (When Indicated)

If antibiotics are warranted based on 3-4 Centor criteria:

• Penicillin V twice or three times daily for 10 days is the first-choice agent 5, 1, 3
• Clarithromycin is an alternative for penicillin-allergic patients 3
• Antibiotics reduce symptoms on day 3 (RR 0.72,95% CI 0.68-0.76) but provide only modest benefit overall 5

What NOT to Do

Avoid these common pitfalls:

• Do NOT prescribe antibiotics to prevent rheumatic fever or glomerulonephritis in low-risk patients - the absolute risk is extremely small in modern settings (NNT 50-200) 5, 1
• Do NOT use antibiotics to prevent suppurative complications (quinsy, otitis media, sinusitis) in most cases - the NNT is 27 or higher for quinsy alone 5, 3
• Do NOT recommend zinc gluconate - conflicting efficacy results and increased adverse effects 5, 1, 3
• Do NOT recommend herbal treatments or acupuncture - inconsistent evidence with methodologically poor quality studies 5, 1
• Do NOT use local antibiotics or antiseptics - lack of efficacy data and mainly viral origin of sore throats 1, 4

Corticosteroids (Limited Role)

Corticosteroids are NOT routinely recommended but can be considered:

• Only in adult patients with severe presentations (3-4 Centor criteria) when used in conjunction with antibiotic therapy 5, 1
• Use single low-dose oral dexamethasone (maximum 10 mg) 1
• Do NOT use in patients with 0-2 Centor criteria 1

Clinical Context

Most sore throats are self-limiting:

• Mean duration is 7 days regardless of treatment 6
• Less than 35% are caused by bacterial infections, yet antibiotics are overprescribed 6
• Even when group A streptococcus is confirmed, antibiotics only hasten symptomatic improvement by 1-2 days 5
• The modest benefits must be weighed against side effects, impact on microbiota, antimicrobial resistance, and costs 5, 1

Red Flags Requiring Urgent Evaluation

Seek immediate assessment if:

• Unilateral tonsillar swelling with uvular deviation (peritonsillar abscess) 7
• Difficulty breathing or swallowing 7
• Drooling or muffled voice (possible epiglottitis) 7, 8
• High fever with severe pharyngitis 7
• Immunosuppression or severe systemic infection 6