No long story can truly be made short. Anecdotally, most clinicians reading these data found they reinforced their preexisting opinion, whether they felt steroids were beneficial or not. For those clinicians who have been using dexamethasone with positive effects in their practice, these data are viewed through the lens of their experience and the prior research. In this view, the statistically negative result is a feature of inadequate sample size, and all the secondary outcomes consistently tilt toward dexamethasone. Symptom relief at 48 hours favored dexamethasone by 8.7 percent, a number needed to treat of 12, and almost all the quality-of-life and resource utilization outcomes likewise show small beneficial effects.

Oral dexamethasone is universally inexpensive, and the preponderance of evidence suggests it’s helpful, so why is this potentially controversial? Why were any clinicians taking the opposing viewpoint that this treatment should not be routinely adopted? This is likely because the intervention has likely been downgraded from “harmless” to “mostly harmless.”

The Risks of Steroids

In certain patients, the deleterious effects of systemic steroids are obvious and avoidable. However, we expect most healthy young patients to tolerate short low-dose courses of steroids without ill effects. A recent publication in BMJ, unfortunately, suggests serious adverse outcomes are substantially more common from steroid exposures.⁴

These authors reviewed a commercial insurance database and a final cohort of more than 1.5 million patients to examine for associations between short-course steroid exposure and sepsis, venous thromboembolism, and fractures. As compared with patients without exposure to steroids, patients prescribed steroids had roughly double the risk for sepsis, a 60 percent increase for venous thromboembolism, and a 25 percent increase for fractures in the five- to 90-day period following exposure. The numbers needed to harm for each of these conditions range from approximately 3,000 for sepsis to 800 for fractures. The harms were not equally distributed across ages, with lower risks for younger patients and increased risks for those older. However, the risks remained substantially increased. These increases in adverse events also held true for short courses and low doses of steroids.
So where does that leave us? Steroids probably do provide some benefit in symptomatic relief of pain from acute pharyngitis but not to the magnitude reflected in earlier trials. At the same time, this treatment is probably not quite as risk-free as previously thought. Ideally, evidence from trials would be robust enough to show signals of which patients were more likely to benefit from steroids, but with just a few hundred in each treatment group, nothing reliable can be gleaned. Ultimately, we will have to wade into a realm of some uncertainty and make individualized assessments of the value of potential benefit as well as of the likelihood of benefit and rare but important harms.

References

1. Barnett ML, Linder JA. Antibiotic prescribing to adults with sore throat in the United States, 1997-2010. JAMA Intern Med. 2014;174(1):138-140.
2. Hayward G, Thompson MJ, Perera R, et al. Corticosteroids as standalone or add-on treatment for sore throat. Cochrane Database Syst Rev. 2012;10:CD008268.
3. Hayward GN, Hay AD, Moore MV, et al. Effect of oral dexamethasone without immediate antibiotics vs placebo on acute sore throat in adults: a randomized clinical trial. JAMA. 2017;317(15):1535-1543.
4. Waljee AK, Rogers MA, Lin P, et al. Short term use of oral corticosteroids and related harms among adults in the United States: population based cohort study. BMJ. 2017;357:j1415.