What oral corticosteroid dose and duration should be prescribed for an otherwise healthy adult with acute tonsillitis?

Oral Corticosteroid Dosing for Tonsillitis

For otherwise healthy adults with severe acute tonsillitis (Centor score 3-4), prescribe a single oral dose of dexamethasone 10 mg alongside appropriate antibiotic therapy; corticosteroids are not recommended for routine use in mild cases or as a multi-day course. 1

Patient Selection Criteria

Corticosteroids should only be offered to adults meeting 3-4 Centor criteria:

• Fever (temperature >38°C)
• Tonsillar exudates
• Tender anterior cervical lymphadenopathy
• Absence of cough 1

Do not prescribe corticosteroids for:

• Mild presentations (Centor 0-2) 1
• Routine sore throat cases 1
• Children with tonsillitis (no demonstrated benefit) 1

Specific Dosing Regimen

Single-dose dexamethasone protocol:

• Dexamethasone 10 mg orally as a single dose 1
• This is the evidence-based regimen from systematic reviews showing modest benefit 1
• Alternative: Prednisolone 30 mg orally as a single dose (equivalent to dexamethasone 6 mg based on 5:1 conversion ratio) 2

Duration: One dose only—multi-day courses are not supported by evidence for acute tonsillitis 1

Mandatory Concurrent Therapy

Corticosteroids must always be prescribed WITH:

Antibiotic Coverage

• Penicillin V or amoxicillin for 10 days to ensure antimicrobial treatment of presumed bacterial tonsillitis 1, 3
• All trials demonstrating steroid benefit included concurrent antibiotics 1
• Alternative: Cefuroxime if penicillin allergy 3

First-Line Analgesics

• Ibuprofen or acetaminophen as first-line adjunctive analgesia for all patients 1
• These provide proven fever and pain control regardless of steroid use 1

Expected Clinical Benefit

Realistic outcome expectations:

• Single-dose dexamethasone shortens throat pain duration by approximately 5 hours 1
• The analgesic effect is modest and appears less pronounced with oral versus other routes 1
• Benefits are most evident in adults with severe presentations (Centor 3-4) 1

Contraindications to Dexamethasone

Exclude patients with:

• Diabetes mellitus or glucose dysregulation 1
• Current exogenous steroid use 1
• Endocrine disorders 1

Common Pitfalls to Avoid

Do not:

• Prescribe multi-day corticosteroid courses for acute tonsillitis—this is not evidence-based and increases adverse effect risk 1
• Use corticosteroids without concurrent antibiotics—all supporting trials included antimicrobial therapy 1
• Prescribe steroids for mild cases (Centor 0-2)—the modest benefit does not justify exposure in low-risk groups 1
• Give aspirin to children with sore throat due to Reye syndrome risk 1

Important distinction:

• Perioperative dexamethasone dosing for tonsillectomy (0.5 mg/kg IV intraoperatively in children) pertains to surgical management and should not be extrapolated to medical treatment of acute tonsillitis 1

Guideline Divergence

Note the following controversy:

• The American College of Physicians and European Society of Clinical Microbiology endorse considering single-dose dexamethasone in severe adult tonsillitis when used with antibiotics 1
• The Infectious Diseases Society of America advises against steroids for Group A Streptococcal pharyngitis 1
• The endorsement is based on clinical-trial data showing modest pain-relief benefits in severe cases 1