Corticosteroids Are Not Recommended for Routine Treatment of Pharyngitis with Infectious Mononucleosis
Corticosteroids should not be used routinely for pharyngitis with infectious mononucleosis, but may be considered at a dose of prednisone 0.5-1.0 mg/kg daily (maximum 60-80 mg daily) for 1-2 weeks in tapering doses only if there is severe pharyngeal edema causing respiratory compromise or airway obstruction. 1, 2
When Corticosteroids Should NOT Be Used
The Infectious Diseases Society of America explicitly recommends against adjunctive corticosteroid therapy for Group A streptococcal pharyngitis (weak, moderate evidence), noting that while corticosteroids decrease pain duration by approximately 5 hours, this minimal benefit does not justify the potential adverse effects of systemic steroids given the self-limited nature of the illness and efficacy of analgesics. 1
For uncomplicated infectious mononucleosis with typical pharyngitis symptoms (sore throat, fever, lymphadenopathy), symptomatic treatment with analgesics and antipyretics is the mainstay of care, not corticosteroids. 2
A Cochrane systematic review of 362 patients found insufficient evidence for steroid efficacy in infectious mononucleosis symptom control, with only 2 of 10 health improvement assessments showing benefit, and that benefit was not maintained beyond 12 hours. 3
When Corticosteroids MAY Be Indicated
Reserve corticosteroids exclusively for life-threatening complications:
Severe pharyngeal edema with impending airway obstruction or respiratory compromise warrants prednisone 0.5-1.0 mg/kg daily (maximum 60-80 mg daily) in tapering doses over 1-2 weeks. 2
Hemodynamic compromise from complications such as severe tonsillar enlargement threatening the airway justifies short-term steroid use. 2
Specific Dosing Regimen (When Indicated)
For adults with severe complications:
Prednisone 60 mg daily orally for 1-2 days initially, then taper over 1-2 weeks. 4
Alternative regimen: 0.5-1.0 mg/kg daily (maximum 80 mg daily) with gradual taper. 1
Critical caveat: One study showed throat pain resolution benefit at 12 hours with 60 mg prednisone for 1-2 days, but this was for general pharyngitis, not specifically mononucleosis, and the benefit was not sustained. 4
Why Routine Use Is Not Recommended
Minimal clinical benefit: Corticosteroids reduce pain duration by only approximately 5 hours in streptococcal pharyngitis, which is clinically insignificant. 1
Self-limited disease: Infectious mononucleosis typically resolves in 2-3 weeks without intervention. 3
Effective alternatives exist: NSAIDs such as ibuprofen and acetaminophen provide adequate pain relief without steroid risks. 1
Potential harms: Although major adverse events were not documented in most trials, case reports describe respiratory distress and acute diabetes onset, though causality is uncertain. 3
Lack of long-term safety data: Trials have not performed adequate long-term follow-up to assess delayed complications. 1, 3
Appropriate Symptomatic Management Instead
Use analgesics/antipyretics as first-line adjunctive therapy:
Acetaminophen or NSAIDs (ibuprofen) for moderate to severe symptoms or high fever (strong, high evidence). 1
Avoid aspirin in children due to Reye syndrome risk (strong, moderate evidence). 1
Adequate hydration and rest guided by the patient's energy level, not enforced bed rest. 2
Critical Pitfalls to Avoid
Do not prescribe corticosteroids for routine symptom relief in uncomplicated infectious mononucleosis—the risk-benefit ratio does not support this practice. 1, 3, 2
Do not use corticosteroids to "speed recovery"—evidence shows no sustained benefit beyond 12 hours for throat pain. 4, 3
Do not overlook true indications for steroids—patients with respiratory compromise or severe pharyngeal edema genuinely benefit and may require urgent intervention. 2
Withdraw patients from contact/collision sports for at least 4 weeks after symptom onset due to splenomegaly risk, regardless of steroid use. 2