Why do clinicians frequently prescribe oral glucocorticoids for uncomplicated upper respiratory infections, and does this prolong recovery?

Why Providers Prescribe Oral Steroids for URIs and Why This May Prolong Recovery

Direct Answer

Oral corticosteroids should NOT be routinely prescribed for uncomplicated upper respiratory infections (URIs) in adults or children, as they provide no benefit for symptom duration or severity and may actually delay recovery. 1, 2

The Evidence Against Oral Steroids for URIs

Adults with Acute Lower Respiratory Tract Infections

The highest quality evidence comes from a 2017 randomized controlled trial of 398 adults with acute lower respiratory tract infections (not asthma). Oral prednisolone 40 mg daily for 5 days showed no reduction in cough duration (median 5 days in both groups) and no clinically meaningful improvement in symptom severity (mean difference -0.20 points on a 0-6 scale, below the minimal clinically important difference of 1.66). 2

Common Cold in General Population

A 2015 Cochrane systematic review of intranasal corticosteroids for the common cold found no benefit for duration or severity of symptoms. While this examined intranasal rather than oral steroids, it demonstrates that corticosteroids in general do not help uncomplicated URIs. 1

Formal Guideline Recommendations

The 2019 IDSA/ATS guidelines give a strong conditional recommendation AGAINST routine use of adjunctive steroids in patients treated for community-acquired pneumonia, and this applies even more strongly to uncomplicated URIs. 3 The 2005 SARS guidelines explicitly state: "Corticosteroids are not indicated for the routine care of patients with uncomplicated SARS" and this principle extends to all uncomplicated viral URIs. 3

Why Providers Mistakenly Prescribe Oral Steroids

Confusion with Appropriate Indications

Providers may be confusing URIs with conditions where steroids ARE appropriate:

• Allergic rhinitis with severe symptoms: A short 5-7 day course may be appropriate for intractable nasal symptoms not responding to intranasal steroids, but this is allergic disease, not infectious URI. 3, 4, 5

• Asthma exacerbations triggered by URI: In children with asthma, early prednisolone at URI onset can prevent wheezing attacks (56% reduction in attacks, 65% reduction in wheezing days). 6 However, this is treating the asthma complication, not the URI itself.

• Severe community-acquired pneumonia: Some evidence suggests benefit in severe CAP with elevated inflammatory markers (CRP >150 mg/L), but this is NOT uncomplicated URI. 3

Misunderstanding of Mechanism

Corticosteroids take 6-12 hours to exert anti-inflammatory effects and provide no benefit in acute viral URI management. 4 The inflammatory response in viral URIs is part of the normal immune response needed to clear the infection—suppressing it may theoretically prolong viral shedding.

Why Oral Steroids May Prolong Recovery

While the evidence shows no benefit, the theoretical mechanisms for potential harm include:

• Immunosuppression: Corticosteroids suppress the immune response needed to clear viral infections
• Secondary bacterial infections: One trial reported cases of sinusitis and acute otitis media occurring in the corticosteroid groups 1
• Delayed viral clearance: By reducing inflammation that is part of the antiviral response, steroids may allow prolonged viral replication

The Correct Approach to URIs

For uncomplicated URIs in adults and children without asthma:

• Supportive care only (hydration, rest, antipyretics for comfort)
• No antibiotics unless secondary bacterial infection develops
• No oral corticosteroids 1, 2

For patients with underlying asthma and URI:

• Consider early short-course oral prednisolone (1 mg/kg daily) to prevent asthma exacerbation 6
• This treats the asthma complication, not the URI itself

For severe allergic rhinitis misdiagnosed as URI:

• First-line: Intranasal corticosteroids (fluticasone, mometasone, triamcinolone) 3, 5
• Only if truly intractable: Short 5-7 day course of oral steroids 4
• Distinguish by clear rhinorrhea, itching, bilateral symptoms (allergic) vs. thick discharge, fever, unilateral symptoms (infectious) 5

Critical Clinical Pitfall

The most dangerous consequence of inappropriate oral steroid use for URIs is that it reinforces patient expectations for "strong medicine" and contributes to polypharmacy without benefit. It also exposes patients to unnecessary corticosteroid adverse effects (hyperglycemia, mood changes, insomnia, immunosuppression) for a self-limited condition. 2