What oral corticosteroid dose should be given to an otherwise healthy adult with severe acute tonsillitis?

Oral Corticosteroid Dosing for Severe Acute Tonsillitis

For an otherwise healthy adult with severe acute tonsillitis (Centor score 3-4), administer a single oral dose of dexamethasone 10 mg alongside appropriate antibiotic therapy. 1

Clinical Decision Algorithm

Patient Selection Criteria

• Use corticosteroids only in adults with severe presentations meeting 3-4 Centor criteria: fever, tonsillar exudates, tender anterior cervical lymphadenopathy, and absence of cough. 2, 1, 3
• Do not use corticosteroids routinely for all cases of sore throat or in patients with mild presentations (0-2 Centor criteria). 2, 4
• Exclude patients with diabetes mellitus, glucose dysregulation, those already on exogenous steroids, or endocrine disorders. 1

Specific Dosing Recommendation

• Dexamethasone 10 mg orally as a single dose is the evidence-based regimen, based on corticosteroid equivalency principles where dexamethasone is 25 times more potent than hydrocortisone. 1
• This single low-dose approach provides adequate anti-inflammatory effect without requiring weight-based calculations in adults. 1

Expected Clinical Benefits

• Pain relief occurs approximately 4.8 hours earlier compared to placebo, with complete resolution of pain occurring roughly 11 hours sooner. 5
• Patients are 2.2 times more likely to experience pain relief at 24 hours and 1.5 times more likely to have complete pain resolution at 48 hours. 5
• The absolute pain reduction at 24 hours is modest—approximately 1.3 points on a 0-10 visual analogue scale. 5
• The total benefit amounts to roughly 5 hours reduction in pain duration, which is clinically modest. 1, 4

Mandatory Concurrent Therapy

Antibiotic Coverage

• Always administer appropriate antibiotics alongside corticosteroids—typically penicillin V (twice or three times daily for 10 days) or amoxicillin for presumed bacterial tonsillitis. 2, 1
• This concurrent antibiotic therapy is essential to ensure antimicrobial coverage and prevent complications such as rheumatic fever. 1
• All evidence for corticosteroid benefit comes from trials where antibiotics were co-administered; no trials have assessed corticosteroids as standalone treatment. 6

First-Line Analgesics

• Prescribe ibuprofen or paracetamol (acetaminophen) as first-line adjunctive therapy for all patients, regardless of whether corticosteroids are used. 2, 4
• NSAIDs like ibuprofen demonstrate significant benefits in reducing fever and pain. 4
• Avoid aspirin in children due to the established risk of Reye syndrome. 1

Important Clinical Caveats

Guideline Divergence

There is notable divergence in guideline recommendations that warrants discussion:

• The Infectious Diseases Society of America explicitly recommends against corticosteroids for Group A Streptococcal pharyngitis, citing minimal clinical benefit, self-limited disease, and potential adverse effects. 4, 3
• In contrast, the American College of Physicians and European Society of Clinical Microbiology suggest consideration in severe adult cases (3-4 Centor criteria) when used alongside antibiotics. 2, 1, 3

This divergence reflects the modest magnitude of benefit (approximately 5 hours pain reduction) weighed against potential risks. 1, 4

Safety Considerations

• Short-term steroid use carries risks including hypertension, cardiovascular disease, osteoporosis, impaired wound healing, infections, mood disorders, and diabetes. 4
• Existing studies were not sufficiently powered to detect adverse effects of short courses of oral corticosteroids. 1
• Six studies reported no adverse effects, and three reported few adverse events with similar incidence in both groups. 5
• Do not use steroids for recurrent episodes as cumulative doses may increase risk, which has not been adequately studied. 5

Population-Specific Limitations

• The effect is considerably smaller in typical primary care populations where most patients do not have severe sore throat. 1, 3
• No significant benefit has been demonstrated in children with sore throat in the medical (non-surgical) setting. 1
• The oral route appears to provide smaller effects compared to other routes of administration. 1

Practical Implementation Steps

1. Assess Centor score: Calculate based on fever, exudates, lymphadenopathy, and absence of cough. 3
2. For Centor 3-4 in adults: Discuss the modest benefits (5 hours pain reduction) against possible side effects with the patient. 1, 4
3. If proceeding: Prescribe dexamethasone 10 mg orally as a single dose. 1
4. Always co-prescribe: Penicillin V for 10 days plus ibuprofen or acetaminophen for symptom control. 2, 1, 4
5. Ensure adequate hydration and supportive care. 7, 8