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We have some concerns regarding the proposal to treat acute pharyngitis with high dose oral steroids.1
Kiderman et al suggest that steroids may reduce short-term pain in a selected group of patients with sore throat presenting in primary care.1 The selection criteria for their study are similar to the Centor criteria and thus likely to select a group with higher probability of positive throat swab, better response to antibiotics and higher complication rate.2 Antibiotics were administered at the treating physicians recommendation and all those with positive swabs were subsequently treated. The authors fail to account for this potential confounder in their analysis. The study had insufficient power to detect differences in relapse rates and more importantly complications. Quinsy, for instance, would be expected in 1:60 cases with the Centor criteria2 and there may be rare complications resulting from the steroid treatment.3 The authors' conclusion that high dose steroids are safe in this context is unjustified. Moreover, this group have a predominantly self-limiting illness and treatment with steroids is likely to parallel antibiotic treatment in producing a medicalising effect and increasing reconsultation rates.4 Any potential benefit in short-term symptom relief must be balanced against unknown harm and altered illness behaviour.
More and better evidence of safety and effectiveness is needed before prescribing steroids can be advocated in acute pharyngitis.
We agree with Moore et al that the study did not have sufficient power to confirm the safety of this treatment, indeed this limitation is clearly stated in the discussion section in our paper. Similar trials with larger samples and longer follow-up times are required to substantiate our findings.
We are, however, surprised by the reference to the Nielsen paper regarding adverse effects of steroid therapy. Nielsen et al studied the incidence of gastrointestinal bleeding following an average dose of the equivalent of 500 mg of prednisone given over a month. Our single dose of 60 mg of prednisnone for 1 or 2 days, is less likely to have serious adverse effects.
We do agree that we did not control for antibiotic use as a potential confounder in in the analysis. There was additional benefit of steroid therapy among patients with swabs positive for streptococcus so the possible confounding role of concurrent antibiotic therapy requires further study.
Finally, regarding their concerns that the use of steroids in pharyngitis might lead to medicalisation and increased consultation rates for the condition, here in Israel we tend to encourage our patients to visit us to obtain effective treatments for their complaints, especially if these are only available on prescription.