What are the recommended medications, including swish and swallow medications like chlorhexidine gluconate (Peridex) or benzocaine (Orajel), for a patient with a sore throat?

Swish and Swallow Medications for Sore Throat

For acute sore throat, systemic analgesics (ibuprofen or paracetamol) are the recommended first-line treatment, NOT swish-and-swallow medications like chlorhexidine gluconate or topical antiseptics. 1, 2

Primary Treatment Recommendations

Ibuprofen or paracetamol should be used as first-line therapy for sore throat pain relief, with ibuprofen showing slightly superior efficacy, particularly at 2 hours post-administration. 1, 2 Both medications are safe for short-term use when used according to directions, with low risk of adverse effects. 2, 3

• Ibuprofen provides the best benefit-risk profile among systemic analgesics and is more effective than paracetamol for pain relief. 2, 4
• Paracetamol (acetaminophen) serves as an effective alternative when ibuprofen is contraindicated or not tolerated. 3

Local Anesthetics (NOT Antiseptics)

If local therapy is desired, local anesthetics are the only topical agents with confirmed efficacy—NOT antiseptics or antibiotics. 4

Three local anesthetics have documented efficacy in clinical trials:

• Lidocaine (8 mg) as lozenges or throat spray 4
• Benzocaine (8 mg) as lozenges or throat spray 4
• Ambroxol (20 mg) with the best documented benefit-risk profile among local anesthetics 4

Phenol-containing products are FDA-approved for temporary relief of minor throat irritation and sore throat. 5

What NOT to Use

Chlorhexidine gluconate (Peridex) and other antiseptics should NOT be recommended for sore throat treatment. 4 While chlorhexidine gluconate is FDA-approved as an oral rinse, it is indicated for gingivitis and periodontal disease—not for sore throat. 6 Local antibiotics or antiseptics lack efficacy data for sore throat and should be avoided due to the predominantly viral etiology of most cases. 2, 3, 4

Additional agents to avoid:

• Zinc gluconate is not recommended due to conflicting efficacy results and increased adverse effects. 1, 2
• Herbal treatments and acupuncture have inconsistent evidence and should not be recommended. 1, 2

Treatment Algorithm

Step 1: Rule out red flags requiring urgent evaluation (severe refractory symptoms, immunosuppression, signs of abscess, epiglottitis, or Lemierre syndrome). 3, 7

Step 2: Initiate systemic analgesics

• Start ibuprofen as first-line therapy for pain control 2, 3
• Use paracetamol as alternative if ibuprofen is contraindicated 3
• Educate patients on proper dosing—many patients do not know how to use paracetamol effectively, leading to perceived treatment failure 8

Step 3: Consider local anesthetics for additional relief

• Add lidocaine, benzocaine, or ambroxol lozenges/sprays if systemic analgesics alone are insufficient 4
• Avoid antiseptics like chlorhexidine for sore throat 4

Step 4: Assess need for antibiotics using clinical scoring

• Use Centor criteria to stratify risk 1, 7
• 0-2 Centor criteria: Antibiotics NOT indicated 1, 2
• 3-4 Centor criteria: Consider delayed prescription or immediate antibiotics, weighing modest symptom reduction (approximately 1 day) against side effects, antimicrobial resistance, and costs 1, 2, 9, 10
• If antibiotics indicated: Penicillin V twice or three times daily for 10 days 1, 2

Important Clinical Pitfalls

Common mistake: Assuming patients have already tried analgesics. GPs often wrongly assume patients have used paracetamol before consulting, without actually exploring this. 8 Many patients do not self-manage with analgesics before seeking care. 8

Common mistake: Inadequate patient education. Patients who do use paracetamol often don't know how to use it effectively (proper dosing, scheduled vs. as-needed), leading to beliefs that it is insufficient for sore throat treatment. 8 Thorough explanation of proper analgesic use improves both patient satisfaction and guideline adherence. 8

Common mistake: Prescribing topical antiseptics. Despite lack of evidence, chlorhexidine and similar antiseptics are sometimes prescribed for sore throat—this practice should be discontinued. 4

Evidence Quality Considerations

The guideline recommendations are based on high-quality evidence (Grade A-1) for systemic analgesics. 1 The evidence for local anesthetics comes from clinical trials demonstrating efficacy, though head-to-head comparisons between agents are limited. 4 The recommendation against antiseptics is based on lack of efficacy data and the predominantly viral etiology of sore throat. 4

Note on antibiotics: While antibiotics reduce symptom duration by approximately 16 hours overall and reduce complications, the absolute benefits are modest. 9, 10 At day three, 82% of placebo-treated patients are symptom-free by one week regardless of antibiotic use. 10 The number needed to treat to prevent one sore throat at day three is less than 6, but increases to 18 at one week. 10