Corticosteroids for treatment of sore throat: systematic review and meta-analysis of randomised trials

Abstract

Objective To estimate the benefits and harms of using corticosteroids as an adjunct treatment for sore throat. Design Systematic review and meta-analysis of randomised control trials. Data sources Medline, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), trial registries up to May 2017, reference lists of eligible trials, related reviews. Study selection Randomised controlled trials of the addition of corticosteroids to standard clinical care for patients aged 5 or older in emergency department and primary care settings with clinical signs of acute tonsillitis, pharyngitis, or the clinical syndrome of sore throat. Trials were included irrespective of language or publication status. Review methods Reviewers identified studies, extracted data, and assessed the quality of the evidence, independently and in duplicate. A parallel guideline committee (BMJ Rapid Recommendation) provided input on the design and interpretation of the systematic review, including the selection of outcomes important to patients. Random effects model was used for meta-analyses. Quality of evidence was assessed with the GRADE approach. Results 10 eligible trials enrolled 1426 individuals. Patients who received single low dose corticosteroids (the most common intervention was oral dexamethasone with a maximum dose of 10 mg) were twice as likely to experience pain relief after 24 hours (relative risk 2.2, 95% confidence interval 1.2 to 4.3; risk difference 12.4%; moderate quality evidence) and 1.5 times more likely to have no pain at 48 hours (1.5, 1.3 to 1.8; risk difference 18.3%; high quality). The mean time to onset of pain relief in patients treated with corticosteroids was 4.8 hours earlier (95% confidence interval −1.9 to −7.8; moderate quality) and the mean time to complete resolution of pain was 11.1 hours earlier (−0.4 to −21.8; low quality) than in those treated with placebo. The absolute pain reduction at 24 hours (visual analogue scale 0-10) was greater in patients treated with corticosteroids (mean difference 1.3, 95% confidence interval 0.7 to 1.9; moderate quality). Nine of the 10 trials sought information regarding adverse events. Six studies reported no adverse effects, and three studies reported few adverse events, which were mostly complications related to disease, with a similar incidence in both groups. Conclusion Single low dose corticosteroids can provide pain relief in patients with sore throat, with no increase in serious adverse effects. Included trials did not assess the potential risks of larger cumulative doses in patients with recurrent episodes of acute sore throat. Systematic review registration PROSPERO CRD42017067808.

Dealing with effect size multiplicity in systematic reviews and meta‐analyses

“…Convergent frameworks are frequent in the health sciences, where inclusion criteria are typically more restrictive and the relevant constructs and measures are likely to be more tightly defined than in other disciplines . A prototypical example is a review of clinical trials of a particular treatment for patients with a particular condition that examines only the outcomes most important to patients …”

“…11 A prototypical example is a review of clinical trials of a particular treatment for patients with a particular condition that examines only the outcomes most important to patients. 12 In contrast, divergent frameworks tend to take an exploratory approach. They address a broad research question with a primary focus on identifying sources of variation among effect sizes that are expected to show substantial statistical heterogeneity such that interpretation of an overall mean effect size might be challenging, or even meaningless.…”

Reporting of financial conflicts of interest in meta-analyses of drug trials published in high-impact medical journals: comparison of results from 2017 to 2018 and 2009

“…As shown in Table 1, impact factors of journals with included publications ranged from 17.2 to 47.8 in general medicine, 11.9 to 24.0 in oncology, 19.3 to 19.9 in cardiology, 10.3 to 10.6 in respiratory medicine, 11.9 to 19.7 in endocrinology, 16.7 to 18.4 in gastroenterology, and 6.3 for the Cochrane Database of Systematic Reviews. The 29 selected meta-analyses evaluated a broad spectrum of pharmacological interventions, including 11 on treatment efficacy [24,29,33,35,36,40,42,[44][45][46][47], 2 on harms [31,50], and 16 [23, 25, 28, 30, 32, 34, 37-39, 41, 43, 48, 49, 51] on both efficacy and harms. Between 2 and 522 RCTs were included in each meta-analysis.…”

“…As shown in Tables 1 and 2 of 29 (6.9%) included metaanalyses, both published in specialty journals [34,43], reported receiving pharmaceutical industry funding, 11 (37.9%) reported non-industry funding [23, 26, 29-32, 35, 40, 49-51], 3 reported no study funding (10.3%) [28,33,46], and the funding source of 13 (44.8%) was not reported [24, 25, 27, 36-39, 41, 42, 44, 45, 47, 48]. Meta-analysis funding sources were reported for 8 of 11 meta-analyses from general medicine journals (72.7%) [23,26,[28][29][30][31][32][33], 5 of 15 (33.3%) from specialty medicine journals [34,35,40,43,46], and all 3 (100%) Cochrane reviews [49][50][51].…”

Consider corticosteroids for acute sore throat, says BMJ review

“…After conducting a systematic review and meta-analysis that included data from the April trial,3 the Rapid Recommendation authors make a weak recommendation to use a single dose of oral corticosteroids in patients presenting with acute sore throat. The recommendation applies across ages but excludes patients under 5 years old.…”