Oral vs. IM Steroids as Supplementary Treatment for Exudative Pharyngitis
Abstract & Commentary
Source: Marvez-Valls EG, et al. A randomized clinical trial of oral versus intramuscular delivery of steroids in acute exudative pharyngitis. Acad Emerg Med 2002;9:9-14.
Previous work has suggested that a single dose of intramuscular (IM) steroid given at the time of initial treatment is more effective than placebo in reducing the duration and severity of pain associated with acute exudative pharyngitis.1,2 Should the advantage—apparently conveyed by the anti-inflammatory effects of these agents—be generalized to steroids administered by the oral route? The authors report on their randomized, double-blind trial comparing dexamethasone 10 mg IM with prednisone 60 mg given orally in a convenience sample of adult patients with exudative pharyngitis presenting to an inner-city emergency department (ED).
Inclusion criteria were as follows: visible evidence of pharyngitis (enlarged tonsils with purulent exudate) together with complaints of sore throat, odynophagia, dysphagia, and fever. A 10 cm visual analog scale (VAS) was employed, and a minimum initial pain score of 5 also was required for study entry. Immunocompromised patients (e.g., AIDS, diabetes mellitus) were excluded, as were those with evidence of peritonsillar abscess, thrush, or ulcerative changes in the pharynx. Pregnant patients also were excluded, as were patients with a history of allergy to steroids or who had received steroid therapy within the three months prior to enrollment. All patients received IM penicillin, but no one received pain medication as part of the study protocol; acetaminophen or ibuprofen for fever or pain control was left to physician discretion. VAS pain scores were recorded at study outset, and then by phone contact at 24 and 48 hours, and ultimately until pain cessation. Patients were prompted with VAS scores from their initial assessment if they did not have their scale (given to them at discharge) available to them at the time of phone contact.
Seventy-eight patients were enrolled in the study, but four were lost to follow-up in each study arm; thus, statistical analysis was performed on a final population of 70 patients (both groups equally represented). Mean VAS scores from both groups were equivalent at study outset. There was no difference in total duration of pain between the IM dexamethasone and oral prednisone groups. Furthermore, there was no difference between the groups in median pain scores at 24-hour and 48-hour follow-up. Amount of adjuvant analgesic use, as well as side effects, did not differ between the two treatment arms. Antibiotic compliance was assured in that all patients in the study population received IM penicillin (none were penicillin allergic). The authors conclude that oral and IM steroids provide similar levels of pain relief in acute exudative pharyngitis.
Commentary by Richard A. Harrigan, MD, FAAEM
Prior work by two of these authors has demonstrated that IM betamethasone (a steroid of equivalent potency to dexamethasone) provided a more rapid onset of pain relief, as well as a shorter time to complete cessation of pain, than placebo.2 Their present endeavor to compare oral and IM routes of steroid delivery parallels the work done by other researchers in the treatment of asthma and croup. If the drugs are equivalent, then the oral route is certainly preferable to an injection. The doses of prednisone and dexamethasone used in this study are roughly equivalent, with 10 mg of dexamethasone corresponding to a dose of approximately 65 mg of prednisone.
The fact that roughly 50% of patients needed to be prompted during phone follow-up as to their previous pain scale scores introduces some bias into the study—as the authors readily acknowledge—but it is difficult to judge the importance of this. As the authors discuss, it is unknown if verbal VAS scores (with the associated need to remind the patient what their first score was) are equivalent to written VAS scores with patients looking at the scale, given that all patients began the study with the VAS visible to them. Perhaps appropriately, subgroup analysis was not performed, and it is mentioned that both study arms had equivalent representation of these patients.
References
1. O’Brien JF, et al. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Ann Emerg Med 1993;22: 212-215.
2. Marvez E, et al. The role of betamethasone in the treatment of acute exudative pharyngitis. Acad Emerg Med 1998;5:567-572.
Dr. Harrigan, Associate Professor of Emergency Medicine, Temple University School of Medicine, Associate Research Director, Department of Emergency Medicine, Temple University Hospital, Philadelphia, Pa., is Editor of Emergency Medicine Alert.
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