Dexamethasone for Sore Throat – What’s Your Bias?

Short Attention Span Summary

Clay Smith, MD,  Twitter

It works! No it doesn’t. Yes it does.
A single dose of dexamethasone 10mg orally did not result in complete resolution of sore throat in 24 hours compared to placebo in this double-blinded RCT.  But it did achieve the secondary outcome, complete resolution at 48 hours: 35.4% in the dex group vs 27.1% in the placebo group, NNT = 12.

People who don’t need antibiotics for sore throat appreciate us doing something to help their pain.  And the BMJ, Cochrane, and NNT all agree the NNT is probably closer to 3.

Spoon Feed
This study says that more patients may feel better with a dose of dexamethasone for sore throat.  But we have to bear in mind the study from yesterday that no treatment is without risk.

Source/Another Spoonful
Effect of Oral Dexamethasone Without Immediate Antibiotics vs Placebo on Acute Sore Throat in Adults: A Randomized Clinical Trial. JAMA. 2017 Apr 18;317(15):1535-1543. doi: 10.1001/jama.2017.3417.

How you view this study depends on your bias.  Journal Watch’s Thomas Schwenk says this is a bad idea.  Ian Steill championed the study on Twitter.

<div
    class="
      image-block-outer-wrapper
      layout-caption-below
      design-layout-inline
    "
    data-test="image-block-inline-outer-wrapper"
>
    <figure
        class="
          sqs-block-image-figure
          intrinsic
        "
        style="max-width:116px;"
    >
      <a class="
            sqs-block-image-link
          " href="http://qxmd.com/r/28418482" target="_blank" rel="noopener">
      <div
          class="image-block-wrapper"
          data-animation-role="image"

data-animation-override
>

      </div>
      </a>
    </figure>
</div>

Peer Reviewer Comments
Thomas Davis, MD,  Twitter

This study is a comparatively large one.  Almost as big as the systematic review published by the BMJ and Cochrane. However, what’s different is this study did not use antibiotics.

The discussion of this article is excellent in describing the less positive outcome in the study compared to the earlier systematic review. In fact, when you read the systematic reviews, the authors state that a study without antibiotics needs to be performed, which led these same authors to perform this study.

Possible explanations:

1. Antibiotic synergy which is suggested in other studies.
2. Steroids work better for patients who have more severe sore throat (i.e. those who PCP’s felt needed antibiotics immediately). However, in this study, only 29 of the 691 eligible patients were excluded because they required immediate antibiotics. 

At the end of the day:
Steroids still work. I offer it to the patient (keeping in mind the article from yesterday on potential harm from short-course steroids).