Steroids for Pharyngitis ======================== þ Dexamethasone - [O'Brien J et al. Dexamethasone as Adjuvant Treatment for Severe Acute Pharyngitis. Ann Emerg Med 1993;22:215.] (small study (25 per group), no cultures done, + 10 mg IM Decadron provided modest relief (pain-free in 15 vs. 35 hrs; start of pain relief in 6 vs. 12 hrs.) + Critique: small numbers means won't detect side effects if infrequent (e.g., increased incidence of peritonsillar abscess). + I'm not sure why not to use a narcotic unless the patient has to drive. - [Marvez-Valls EG, Ernst AA, Gray J, Johnson WD. The role of betamethasone in the treatment of acute exudative pharyngitis [see comments]. Acad Emerg Med 1998; 5:567-72.] + used Celestone Soluspan 2 cc + OBJECTIVE: To compare betamethasone with placebo as an adjuvant to antibiotic therapy in the treatment of acute exudative pharyngitis. METHODS: The study was a randomized, doubled-blind, placebo-controlled, single-center, parallel, outpatient clinical trial. After consent was obtained, each patient was asked to rate his or her pain on a 10-cm numbered visual analog scale (VAS; 0-10). All of the patients received injectable benzathine penicillin. If allergic to penicillin, they were started on a 10-day course of polyenteric-coated erythromycin (PCE). Each patient was randomized to receive either i.m. betamethasone or i.m. placebo. All patients were contacted by telephone at 24 and 48 hours by one of the study investigators and asked to rate their pain based on another VAS. If their pain was not resolved by 48 hours, they were called again daily between the third and seventh days after the initial visit to determine the time of pain resolution. RESULTS: A total of 92 patients were enrolled in the study, with 46 randomized to receive placebo and 46 to receive betamethasone. Eight patients were excluded from the statistical analysis because of inability to obtain follow-up. Demographic comparison showed that gender distributions, ages, mean initial pain scores, mean times to the first and second follow-up calls, and treatment regimens were similar in the 2 groups. There were significantly better pain scores for the betamethasone group at first follow-up (p = 0.0005), at second follow-up (p = 0.004), and in number of hours until relief of pain (p = 0.004). When only those patients with a positive culture for a streptococcus species were analyzed, there also were significant reductions in pain score at the first (p = 0.006) and second (p = 0.02) follow-up visits. CONCLUSION: Pain relief was greater and more rapid in patients treated with betamethasone as an adjuvant therapy in acute exudative pharyngitis. A Randomized Clinical Trial of Oral versus Intramuscular Delivery of Steroids in Acute Exudative Pharyngitis. Marvez-Valls EG, Stuckey A, Ernst AA. Department of Medicine, Division of Emergency Medicine, Louisiana State University (EGM, AS), New Orleans, LA. Acad Emerg Med 2002 Jan;9(1):9-14 Previous study has shown that the use of intramuscular (IM) steroid leads to improved symptoms in patients with group A beta-hemolytic streptococcus (GABHS). OBJECTIVE: To compare oral with IM steroids as an adjunct to antibiotic therapy in the treatment of acute exudative pharyngitis. The null hypothesis was that there would be no difference in effectiveness of oral versus IM steroids. METHODS: The study was a randomized, double-blind outpatient clinical trial. After consent was obtained, each patient was asked to rate his or her pain on a 10-cm numbered visual analog scale (VAS; 0-10). All of the patients received injectable benzathine penicillin or, if allergic to penicillin, a ten-day course of polyenteric-coated erythromycin. Each patient was randomized to receive either injectable steroid plus oral placebo or injectable placebo plus oral steroid. All medications were given in the emergency department. All patients were contacted by telephone at 24 hours (first follow-up) and 48 hours (second follow-up) by one of the study investigators and asked to rate their pain based on another VAS. If their pain was not resolved by 48 hours, they were called again daily for the third to seventh day after the initial visit. The time to total resolution of the sore throat was documented. The main outcome measures were time to complete relief of pain and VAS scores. Pain medication was not controlled; however, use of pain medications and amounts were recorded. RESULTS: A total of 78 patients were initially enrolled in the study. Eight patients were excluded from the statistical analysis because of inability to follow up. A total of 70 were entered, with 35 randomized to IM steroid plus oral placebo and 35 to IM placebo plus oral steroid. There was no difference in pain scores for the oral versus IM group at first follow-up (p = 0.13) and second follow-up (p = 0.82), and in number of hours to relief of pain (p = 0.06). Using repeated-measures analysis of variance, no difference in the effects of the two medications over time was detected (p = 0.83). CONCLUSIONS: The results of this clinical trial suggest that oral steroid and IM steroid provide similar levels of pain relief in acute exudative pharyngitis. Send reply to: "EMED-L a list for emergency medicine practitioners." From: "James Li, MD" Subject: Steroids in pharyngitis... To: EMED-L@ITSSRV1.UCSF.EDU > is anyone out there treating pharygitis with steroids as an adjuvant to > antibiotics for symtomatic reduction of pain/swelling? dosage and > references? Thanks. Dr. Liu, The following is from a lecture handout I gave to our residents at Charity Hospital last year. Reference [6] has recently been published concluding that IM betamethasone (Celestone), as previously demonstrated with IM dexamethasone, speeds resolution of symptoms in acute pharyngitis. The study was well done (having enrolled patients myself), blinded, randomized, and also demonstrated minimal to no complications in several hundred treated patients. Enough residents were persuaded that the last time I had a URI (not even a sore throat) I was chased around the e.r. by a fellow resident wielding a syringe and needle before managing to escape into the radiology reading room. (Dr. Fusco has personal experience with this remedy!) The comments regarding use of benzathine penicillin are in the context of an indigent population with poor outpatient medication compliance. Dr. DeBard's comments on potential anaphylaxis are duly recalled. James Li, MD Mount Auburn Hospital Cambridge, Massachusetts (jamesli@cheerful.com) For compliance reasons, single-dose benzathine penicillin ($11/1.2mU) is recommended for Group A beta-hemolytic streptococcal (GABHS) pharyngitis or tonsillitis. If oral penicillin must be used, twice-daily dosing for improved patient compliance has been found to be as effective as qid dosing ($2/500mg bid for 10d). A 10-day course is still necessary for eradication [1]. Because throat cultures are often impractical for ED use, various criteria correlating clinical findings with positive cultures have been developed [2]. According to one authority, patients presenting with both pharyngitis and all of the following findings should be treated in the emergency department for presumed GABHS: fever exceeding 38.3o C, pharyngeal or tonsillar exudates, and tender anterior cervical adenopathy [3]. Another authority adds lack of cough, but recommends empiric treatment if two or more of these four findings are present [4]. Two recent trials have demonstrated shortened clinical courses of pharyngitis when steroids (dexamethasone and betamethasone) were also administered with antibiotics [5] [6]. Steroids should always be administered with antibiotics in this setting, to prevent overwhelming bacteremia. Death in a previously healthy adolescent has been reported from disseminated infection associated with adjunctive steroid treatment for pharyngitis [7]. Steroids not recommended in HIV+, pregnancy, thrush, or ulcerative pharyngitis. References: [1] Dajani AS, et al. Treatment of acute streptococcal pharyngitis and prevention of rheumatic fever.: American Heart Association. Pediatrics 1995;96:758. [2] Tompkins R, et al. An analysis of the cost-effectiveness of pharyngitis management and acute rheumatic fever prevention. Ann Intern Med 1977;86:481. [3] Group A Beta-Hemolytic Streptococcal Pharyngitis, in Rosen P, ed, Emergency Medicine vol 2. St. Louis: Mosby-Year Book;1992. [4] Phayringitis, in Mengert TJ, Emergency Medical Therapy 4th ed. Philadelphia: Saunders Co;1996:480. [5] O'Brien JF, Meade JL, Falk JL. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 1993;22:212-215. [6] Marvez E, Gray J. Betamethasone for exudative pharyngitis. Unpublished data. 1996. ***This was published in Annals last year. Currently in-flight to Denver, don't have the exact refs at hand. E-mail me if you need it.*** [7] Shane SA, Wollman M, Claassen D. Herpes simplex dissemination following glucocorticoids for upper airway obstruction in an adolescent girl. Pediatr Emerg Care 1994;10:160-162.