Steroids in Adult Sore Throat and Upper Respiratory Infection
Corticosteroids are not routinely recommended for adults with sore throat, but can be considered as adjunctive therapy alongside antibiotics in adults with severe presentations (Centor score 3-4), using a single oral dose of dexamethasone 10 mg. 1, 2
Patient Selection Algorithm
Assess severity using Centor criteria (fever, tonsillar exudates, tender anterior cervical lymphadenopathy, absence of cough): 1, 2
Centor 0-2 (mild-moderate): Do NOT prescribe corticosteroids. The modest benefit does not justify exposure in low-risk groups. 1, 3
Centor 3-4 (severe): Consider a single dose of corticosteroids only when used alongside appropriate antibiotic therapy. 1, 2
Evidence for Benefit
The clinical benefit is modest but statistically significant: 4
Corticosteroids increase complete pain resolution at 24 hours by 2.4 times (5 patients need treatment to prevent one continuing to experience pain). 4
Complete pain resolution at 48 hours increases by 1.5 times. 4
Mean time to pain relief is reduced by approximately 6 hours, and complete resolution occurs roughly 11-12 hours earlier. 5, 4
Pain scores improve by an additional 10-14% at 24 hours. 5, 4
However, one high-quality RCT found no significant benefit at 24 hours (22.6% vs 17.7% complete resolution, p=0.14), though benefit emerged at 48 hours (35.4% vs 27.1%, p=0.03). 6 This suggests the effect may be smaller in typical primary care populations where most patients lack severe presentations. 2
Mandatory Concurrent Therapies
When prescribing corticosteroids, you must provide: 2, 3
Appropriate antibiotic coverage: Penicillin V twice or three times daily for 10 days, or amoxicillin if penicillin-resistant strains suspected. All trials demonstrating steroid benefit included concurrent antibiotics. 1, 2
First-line analgesics: Ibuprofen or acetaminophen (paracetamol) for all patients, regardless of steroid use. These provide proven fever and pain control. 1, 2
Specific Dosing Regimen
For adults with Centor 3-4: Single oral dose of dexamethasone 10 mg. 2 This dose is based on corticosteroid equivalency principles (dexamethasone is 25 times more potent than hydrocortisone), providing adequate anti-inflammatory effect without weight-based calculations. 2
Contraindications to Steroid Use
Exclude patients with: 2
- Diabetes mellitus or glucose dysregulation
- Current exogenous steroid use
- Endocrine disorders
Critical Guideline Divergence
Important caveat: The Infectious Diseases Society of America explicitly advises against adjunctive corticosteroids for Group A streptococcal pharyngitis, citing minimal clinical benefit (only 5 hours pain reduction), self-limited disease course, and potential adverse effects. 3 This contrasts with the American College of Physicians and European Society of Clinical Microbiology recommendations that permit consideration in severe cases. 1, 2, 3
Common Pitfalls to Avoid
Do not use steroids as standalone therapy without antibiotics—no trials support this approach. 5, 4
Do not prescribe routinely for all sore throats—the effect is considerably smaller in typical primary care where most patients lack severe symptoms. 2, 3
Do not use in children—no significant benefit has been demonstrated in pediatric populations with acute pharyngitis. 2
Avoid aspirin in children due to Reye syndrome risk. 2
Safety Considerations
Adverse event reporting was poor across trials, and studies were not adequately powered to detect harms from short corticosteroid courses. 2, 4 No differences in recurrence, relapse, or reported adverse events were found between corticosteroid and placebo groups, but this may reflect inadequate surveillance rather than true safety. 5, 4
The oral route appears less effective than intramuscular administration, though oral dosing remains more practical for outpatient management. 2