Exudative Pharyngitis: Do Steroids Help?
abstract & commentary
Synopsis: The authors conclude that as an adjunct to antibiotic therapy, betamethasone appears to lessen the time to pain relief in patients with acute exudative pharyngitis, and that this treatment may be most effective in patients with streptococcal pharyngitis.
Source: Marvez-Valls EG, et al. Acad Emerg Med 1998; 5:567-572.
This prospective, randomized, double-blinded, placebo-controlled study evaluated the efficacy of betamethasone as an adjunct to antibiotic therapy for patients with exudative pharyngitis. All patients with exudative pharyngitis were treated with antibiotics, either IM penicillin or oral erythromycin. Patients were randomized to receive either IM saline or betamethasone. Patients were asked to rate their pain on a visual analogue scale (VAS) at the time of treatment. Each patient was called periodically to rate their pain on the VAS compared to their initial rating. Marvez-Valls and colleagues did not ask about analgesic use. Not all patients had throat cultures performed.
Patients receiving betamethasone started to feel relief five hours earlier and had complete resolution of pain 14 hours earlier than the placebo group. The number of days of missed school or work was not significantly different between the two groups. In patients whom were cultured, those in the culture negative group did not show any differences in pain scores comparing betamethasone to placebo. Marvez-Valls et al conclude that as an adjunct to antibiotic therapy, betamethasone appears to lessen the time to pain relief in patients with acute exudative pharyngitis, and that this treatment may be most effective in patients with streptococcal pharyngitis.
Comment by Glenn C. Freas, MD, JD, Facep
In a previous study by O’Brien and associates, dexamethasone was shown to be an effective adjunct to antibiotic treatment for acute pharyngitis.1 Since that study, many emergency physicians used steroids in the treatment of acute pharyngitis to more rapidly decrease the pain associated with this common disease. This study will undoubtedly be cited by many of our colleagues to further justify this practice. Nonetheless, there are persistent questions and concerns about the efficacy and cost effectiveness of this practice. Some of them are highlighted in the accompanying editorials in the same issue of Academic Emergency Medicine.
One area of concern is the validity of the visual analogue scale that was used in this study and its applicability to the pain of pharyngitis. Cydulka points out that even if we assume that the VAS can be applied to the setting of acute pharyngitis pain, the clinical differences between the placebo group and the betamethasone group described at 24 hours disappear at 48 hours.2 Half of the patients had to be reminded of their initial rating on the VAS and did not have the actual visual scale in front of them at home. This is no longer a "visual" analogue scale.
Marvez-Valls et al acknowledge that the lack of control for analgesic use may also call their findings into question. Also, follow-up did not include questions about compliance in the group that was given erythromycin (9% of the patients who received betamethasone were given erythromycin). Finally, as with O’Brien’s study, there was no attempt to document the cost-effectiveness of treatment with betamethasone. Do hours of less pain justify the use of an IM injection? The risk of needle stick to health care personnel must also be factored into any cost (risk)-benefit analysis.
For the above reasons, I have been slow to jump on the steroid bandwagon for treatment of pharyngitis. While I am sensitive to the need to help our patients with the pain of acute pharyngitis, I am still not convinced that the routine use of steroids for all patients with this common disease is cost-effective and warranted.
1. O’Brien JF, et al. Ann Emerg Med 1993; 22:212-215.
2. Cydulka RK. Acad Emerg Med 1998;5:557-559.