5/12/2017 Symptomatic treatment of acute pharyngitis in adults - UpToDate

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Symptomatic treatment of acute pharyngitis in adults

Author: Wendy Stead, MD

Section Editor: Mark D Aronson, MD
Deputy Editor: Howard Libman, MD, FACP

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Nov 2017. | This topic last updated: Nov 02, 2017.

INTRODUCTION — Acute pharyngitis is one of the most common conditions treated in office practice, with
millions of visits annually in the United States [1].

This topic will address options for the symptomatic relief of throat pain in adults with acute pharyngitis of viral
(the most common cause of infectious sore throat in adults) or bacterial etiology. One goal is to avoid
overprescribing antibiotics while maintaining or enhancing rapport with patients by meeting both patient and
clinician expectations about types of treatments and symptom relief.

The evaluation of the adult patient with acute pharyngitis, the antibiotic treatment of streptococcal
tonsillopharyngitis, the diagnosis and treatment of season influenza, and issues specific to pharyngitis due to
mononucleosis are discussed separately. (See "Evaluation of acute pharyngitis in adults" and "Treatment and
prevention of streptococcal tonsillopharyngitis" and "Diagnosis of seasonal influenza in adults" and
"Treatment of seasonal influenza in adults" and "Clinical manifestations and treatment of Epstein-Barr virus
infection".)

The evaluation and treatment of less common but serious causes of sore throat including epiglottitis,
peritonsillar abscess, submandibular and retropharyngeal space infections, and acute human
immunodeficiency virus (HIV) infection, are discussed separately. (See "Evaluation of acute pharyngitis in
adults", section on 'Excluding dangerous conditions' and "Evaluation of acute pharyngitis in adults", section
on 'Non-infectious causes' and "Epiglottitis (supraglottitis): Clinical features and diagnosis" and "Epiglottitis
(supraglottitis): Management" and "Peritonsillar cellulitis and abscess" and "Deep neck space infections" and
"Acute and early HIV infection: Clinical manifestations and diagnosis".)

GENERAL CONCEPTS — Most adult patients with acute pharyngitis have a viral illness for which they are
seeking relief of sore throat pain, which is important for patient comfort and improves the patient’s ability to
remain appropriately hydrated. A discussion of options for pain relief should accompany the evaluation for the
etiology of the throat pain, which is most likely to be a self-limiting virus, less likely a bacterium requiring
antibiotics (eg, Streptococcus or gonococcus) [2], and much less likely, a very serious infection (eg,
epiglottitis, peritonsillar abscess, deep space infections, or acute human immunodeficiency virus [HIV]).

The evaluation of acute pharyngitis is discussed elsewhere. (See "Evaluation of acute pharyngitis in adults",
section on 'Evaluation'.)

Approach to symptom control — Pain relief approaches for acute pharyngitis in adults include systemic
oral analgesics, topical therapies, and environmental measures. These approaches have not been directly
compared. Considerations when choosing among them include patient factors (eg, sore throat symptom
severity, presence of concomitant symptoms, and any patient comorbidities) and therapy-related factors (eg,
rapidity of onset of action, duration of effective relief, and side effect profile of each treatment). In general, we
suggest a systemic oral analgesic. However, topical therapies are reasonable for patients who want to avoid

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systemic therapy or are at higher risk for side effects from systemic therapy. Additionally, using more than
one therapy could provide the most effective symptom relief. If patients use more than one pharmacologic
therapy, they should be cognizant of active ingredients in the preparations to avoid exceeding the
recommended dose.

● Over-the-counter oral analgesics, including nonsteroidal antiinflammatory drugs (NSAIDs),

acetaminophen, and aspirin, typically have a duration of effectiveness of several hours. They generally
act within one to two hours to relieve sore throat symptoms due to acute pharyngitis. Oral analgesics act
systemically; thus, they will address concomitant symptoms that may accompany sore throat, such as
fever or headache. The choice among oral analgesics, and permissible maximum dosages, may be
limited by such factors as renal or hepatic dysfunction or by current or prior gastric irritation or reflux
symptoms. We typically start at a low dose and titrate up. (See 'Choosing an oral analgesic' below.)

● Topical treatments applied locally to the throat via lozenge or spray, or via beverages or foods (eg, ice,
tea, soup, and honey), are generally quicker-acting than oral analgesics, and they typically have a
shorter duration of pain relief which may necessitate frequent re-dosing. There is no evidence that a
particular topical lozenge or spray is superior in efficacy. The choice among them is dependent on
availability and clinician or patient preference. We do encourage patients to consume warm fluids, teas
with honey, and soups and to melt ice chips or popsicles in their mouths before swallowing them. (See
'Therapies applied topically to the throat' below.)

Nonpharmacologic environmental approaches may also be of benefit. These approaches include adjusting
humidity to avoid a dry environment and avoiding exposure to irritants such as tobacco smoke. (See 'Helpful
environmental approaches' below.)

Glucocorticoid treatment is generally not recommended due to the potential for harms balanced against the
only slight improvement in rate of pain reduction as compared with oral analgesics. However, steroids may be
appropriate in the exceptional patient who presents with severe throat pain and/or inability to swallow. (See
'Limited role of glucocorticoids' below.)

If the patient’s only symptom is throat pain, we discourage use of multisymptom preparations (eg,
combination analgesic and decongestant) containing ingredients to improve symptoms the patient is not
experiencing, in order to minimize the side effect potential.

Avoid antibiotic overprescribing — Prescribing antibiotics that are not indicated for a specific infection puts
the patient at risk for antibiotic side effects and increases the community risk of bacterial resistance.
Additionally, prescribing antibiotics for sore throat increases the likelihood that a patient will make return visits
to medical providers for similar symptoms, presumably due to "medicalization" of a typically self-limited illness
[3].

Even when appropriately treating documented bacterial pathogens such as group A Streptococcus,
antibiotics contribute minimally to the speed with which symptoms of pharyngitis improve. Nonetheless,
overtreatment of acute pharyngitis continues to represent a major cause of inappropriate antibiotic use [4].

In an effort to avoid unnecessary antibiotic prescriptions, we discuss the risks and benefits of antibiotic and
non-antibiotic approaches, including the value of non-antibiotic pain relief; validate patient’s goals and
concerns; educate them about the expected clinical course and time to improvement; and emphasize open
communication to bring worsening symptoms or lack or expected improvement to attention. This discussion
may be facilitated by use of patient education material (see 'Information for patients' below). A tool from the
US Centers for Disease Control and Prevention (CDC) that can help patients understand more about
treatment of their symptoms is also available [5]. (See "Antimicrobial stewardship in outpatient settings",
section on 'Education and expertise'.)

Contrary to the impression of many clinicians that acquiring an antibiotic prescription is the most important
priority for patients who visit a primary care clinic for acute sore throat [6,7], in an observational study of 300

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visits for acute pharyngitis, over 80 percent of patients were interested in pain relief, reassurance, and
information about their illness [7]. Only 38 percent were hoping specifically for an antibiotic prescription.
Further, the subgroup of patients who considered receipt of an antibiotic very or rather important valued pain
relief more than those who considered an antibiotic of little or no importance. The multivariate analysis
showed that hope for pain relief remained a strong predictor of the desire to receive an antibiotic prescription,
suggesting that patients believe an antibiotic offers the best approach for achieving this goal. Additionally,
data from a study of pediatric visits for upper respiratory infections showed that unnecessary antibiotic usage
decreased and patient satisfaction increased when education was provided both about how to decrease
symptoms and about why antibiotics were not indicated [8].

SYSTEMIC ORAL THERAPIES — Systemic oral therapy is quite effective at reducing pain of acute
pharyngitis in adults. Acetaminophen and nonsteroidal antiinflammatory drugs (NSAIDS) remain the two most
rigorously studied for this indication. The use of glucocorticoids for treatment of most sore throat pain is
generally not suggested due to the potential for serious side effects compared with the slight reduction in
duration of sore throat pain.

Choosing an oral analgesic — Oral analgesics are readily available, and systematic reviews and
randomized trials have confirmed the efficacy of each systemic analgesic studied for treating acute sore
throat [9-16]. Data from randomized trials suggest that NSAIDs are more effective than acetaminophen
[9,10]. However, it is uncertain whether the efficacy benefit is clinically meaningful in treating pharyngitis.

Given the lack of clear evidence of clinical superiority of a particular agent, the choice of systemic analgesic
may be guided by patient preference, which is often based on prior favorable experience with a particular
agent. However, it is important for patients with certain comorbidities to avoid choosing an oral analgesic
which could exacerbate them; for example, patients with gastroesophageal reflux disease, ulcer history, or
significant renal insufficiency should be advised to use acetaminophen due to the potential for gastrointestinal
irritation or bleeding or worsening renal function with NSAIDs or aspirin. (See "Nonselective NSAIDs:
Overview of adverse effects" and "Aspirin: Mechanism of action, major toxicities, and use in rheumatic
diseases", section on 'Major side effects and other concerns' and "Management of pain in patients with
advanced chronic liver disease or cirrhosis", section on 'Acetaminophen (paracetamol)'.)

We suggest initiating an oral analgesic at the lower end of the recommended adult therapeutic dose (eg,
ibuprofen 200 to 400 mg, aspirin 325 mg, or acetaminophen 325 mg). If further pain relief is required, the
dosage can be titrated up by the patient while staying within the recommended dosing range.

Guidelines from the Infectious Disease Society of America (IDSA) advise use of aspirin, acetaminophen, or
an NSAID as adjunctive treatment to antibiotic in the management of streptococcal pharyngitis in adults [11].

NSAID efficacy — Ibuprofen 200 to 400 mg decreases acute sore throat pain by 32 to 80 percent at two
to four hours [15]. Several randomized trials in different countries among patients with acute pharyngitis have
shown that ibuprofen produces a significantly greater reduction in sore throat pain compared with
acetaminophen [9,10,17]. As an example, a United States double-blind randomized trial of 120 outpatients
with acute sore throat compared ibuprofen 400 mg, acetaminophen 1000 mg, and placebo, using a visual
analog scale (0 to 100) to measure pain intensity compared with baseline. Ibuprofen and acetaminophen
were similarly effective at two hours; at three to six hours, pain reduction was greater with ibuprofen than
acetaminophen (pain intensity difference 75 versus 50 at three hours). Compared with placebo, both
ibuprofen and acetaminophen reduced pain intensity over the six hours studied [9].

Aspirin efficacy — Aspirin has demonstrated effective sore throat relief from one through six hours after
ingestion. In a double-blind, placebo-controlled trial of 272 adult patients with acute sore throat associated
with other symptoms of upper respiratory infection, aspirin (two 400 mg effervescent tablets in water) reduced
the intensity of sore throat pain at two, four, and six hours in the intervention group [12]. Headaches and
muscle aches/pains were also significantly reduced in the treatment group, with no serious adverse events
reported. In another randomized controlled study of 177 adult patients with acute sore throat, time to

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meaningful pain relief and pain intensity were decreased in the group treated with a fast-release aspirin
formulation (two 500 mg tablets containing sodium carbonate as a disintegrant and small particles of aspirin)
compared with placebo [18].

Acetaminophen efficacy — Acetaminophen 1000 mg decreases acute sore throat pain by approximately
50 percent after three hours. Acetaminophen in combination with sodium bicarbonate, a formulation
associated with more rapid absorption of acetaminophen than standard acetaminophen tablets, was found to
provide rapid relief in a randomized controlled trial in 241 adult patients with acute sore throat [19]. A single
dose of acetaminophen 500 mg and sodium bicarbonate 630 mg resulted in significantly greater pain relief
than placebo starting at 15 minutes post-dose and continuing through to six hours. Effervescent products
containing acetaminophen and sodium bicarbonate are available in various dose ratios in different countries.

Limited role of glucocorticoids — We suggest not prescribing glucocorticoids on a routine basis for the
relief of pain associated with an acute sore throat, regardless of etiology. The use of glucocorticoids depends
on severity of illness and should be restricted to the exceptional patient who presents with severe throat pain
and/or inability to swallow.

Although there is evidence that glucocorticoid use can slightly decrease the duration of throat pain,
analgesics such as NSAIDs or aspirin are also effective and carry significantly less risk of toxicities such as
serious mood changes or hyperglycemia, which are well described with short-term steroid use. For similar
reasons, IDSA guidelines recommend against the use of glucocorticoids for patients with streptococcal
pharyngitis [11]. Others have made a weak recommendation for a single dose of oral corticosteroids for
symptom relief of pharyngitis, emphasizing shared decision-making with the patient [20]. (See "Major side
effects of systemic glucocorticoids".)

Systematic reviews of randomized trials assessing the efficacy of glucocorticoids for pain reduction in acute
pharyngitis have generally found only modest benefit (slightly quicker reduction of pain by up to
approximately half a day) [14,21-23]. In one meta-analysis of 10 randomized trials that included 1426 children
and adults, one to two days of adjunctive glucocorticoids (oral or intramuscular dexamethasone,
betamethasone, or prednisone) reduced the time to pain relief onset by approximately five hours (7.4 versus
12.3 hours) and the time to complete pain resolution by 11 hours (33 versus 44 hours) compared with
placebo [23]. A higher proportion of patients taking glucocorticoids had complete pain resolution at 24 to 48
hours. An earlier meta-analysis had similar findings [22].

However, there were important limitations with these studies: antibiotics were coadministered in most of the
trials, and use of concurrent analgesics was allowed and rarely controlled, making it difficult to isolate the
pain-relieving effect of one treatment versus another. Glucocorticoid formulations given were heterogeneous,
given at different doses and time intervals and by different routes of administration.

Most of the trials occurred in the emergency setting, so generalizability to patients in an office setting is
uncertain. In one office-based randomized controlled trial that evaluated a single dose of dexamethasone 10
mg for adults who visited a primary care clinician for acute pharyngitis and were not given an immediate
prescription for antibiotics, the benefit was also small [24]. There was no difference between dexamethasone
and placebo in the rate of full sore throat relief at 24 hours; there was only a small difference at 48 hours (35
versus 27 percent with placebo, relative risk [RR] 1.31, 95% CI, 1.02 to 1.68).

Although no difference in rates of adverse side effects was seen with short-term glucocorticoid use, in some
studies the number of patients studied was too small to detect potentially rare but serious toxicities resulting
from even such limited courses of steroids [22-24]. One meta-analysis highlighted the varied data collection
methods about adverse effects in the included studies [22-24].

Data on the use of glucocorticoids for mononucleosis throat pain and swelling, specifically, are discussed
separately. (See "Infectious mononucleosis in adults and adolescents", section on 'Symptomatic treatment'.)

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THERAPIES APPLIED TOPICALLY TO THE THROAT — Several local therapies for sore throat in the form
of lozenges/drops, throat sprays, gargles, and teas are available for relief of pain related to pharyngitis. In
addition, adjusting the temperature and texture of beverages and foods helps to relieve the pain of
swallowing, which can limit hydration and caloric intake during acute pharyngitis.

Advantages of local therapies include direct application of the pain relief intervention in high concentration to
the area of inflammation and decreased risk of toxicity compared to systemic administration of certain
medications. There is also a much more rapid onset of effectiveness, although duration of effectiveness may
be shorter than for systemic therapies. Ease of administration is also a consideration; some therapies are
easier to access quickly (lozenges, sprays), while others may require preparation (teas, gargles).

We generally suggest that topical therapies be used as an adjunct or an alternative to an oral analgesic for
significant sore throat pain. There is no evidence that a particular topical lozenge or spray is superior in
efficacy. The choice among them is dependent on availability and clinician or patient preference. We do
encourage patients to consume warm fluids, teas with honey, and soups and to try letting ice chips or
popsicles melt in their mouth.

Topical therapies have been studied to varying degrees. One study used scintigraphy to compare the delivery
efficacy of technetium-labeled lozenges, tablets, sprays, and gargles in the mouth and throat of healthy
volunteers [25]. Lozenges and tablets to be sucked achieved higher initial deposition in the mouth and throat
and had slower rates of clearance compared with throat sprays and gargles, suggesting that lozenges and
tablets could be more effective for symptomatic treatment of pharyngitis [25].

Lozenges — Many different kinds of lozenges and throat drops are marketed for over-the-counter use for
symptomatic treatment of sore throat. These can provide quick-onset, short-duration relief of throat pain. It is
not clear that any one type offers advantages over the other. We typically suggest menthol because of its
availability, but other options are reasonable alternatives if patients prefer them.

In the United States, active ingredients in lozenges that patients should look for when choosing one include
menthol, dyclonine, and benzocaine.

● Menthol has been shown to possess anesthetic properties, although it has not been studied specifically
for symptomatic treatment of pharyngitis pain [26]. Several over-the-counter products for relief of sore
throat contain the active ingredient menthol, either alone (as with many cough drop brands) or in
combination with other agents.

● Dyclonine, a topical anesthetic, is found in over-the-counter sore throat lozenges.

● Benzocaine is an effective topical agent found in throat lozenges. However, lozenges use the same
ingredient as benzocaine spray, which carries a risk of the patient developing methemoglobinemia, a
rare but serious and potentially fatal adverse effect. Though adverse reactions to benzocaine lozenges
are rare, the US Food and Drug Administration (FDA) issued a public health advisory regarding this risk
associated with benzocaine sprays, and the agency continues to receive reports of the occurrence of
methemoglobinemia.

Benzocaine was studied in a small trial in Germany prospectively evaluating the pain-relieving effects of
two different formulations containing 8 mg of benzocaine (a newly formulated lozenge versus a
previously marketed pastille) in 246 adults with acute viral pharyngitis [27]. At least 50 percent pain
intensity reduction was reported in 24 percent of patients after the first lozenge dose, with no difference
between groups. This response rate was lower than expected. Better effectiveness was seen in a
smaller trial of 43 patients who received benzocaine-cetylpyridinium lozenges; alleviation of pain was
reported in 84 percent of patients within 15 minutes, although the degree of pain relief was not quantified
[28]. A randomized controlled trial evaluated the effects of 8 mg benzocaine lozenges versus placebo in
165 patients with uncomplicated sore throat and found a decrease in pain and faster time to pain relief in
the benzocaine group [29].

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In other countries, other effective lozenge ingredients studied for relief of sore throat pain include lidocaine,
ambroxol, amylmetacresol and 2,4-dichlorobenzyl alcohol lozenges (AMC/DCBA), and flurbiprofen.

● Lidocaine hydrochloride lozenges (8 mg) produced improvement in pain intensity over two hours after
the first dose in a randomized placebo-controlled trial in Germany involving 240 adults with moderate to
severe throat pain of recent onset without evidence of bacterial etiology [30]. The improvement persisted
for the two days of follow-up during which patients could use up to 11 additional lidocaine lozenges. The
treatment was well tolerated without an increase in adverse effects in the lidocaine-treated group.

● Ambroxol, a local anesthetic, has been evaluated in multiple industry-sponsored randomized placebo-
controlled trials in ambulatory adults in Germany [31-33]. A review of five randomized trials among 1713
patients with acute, uncomplicated "moderate" or "severe" sore throat of recent onset found that in four
trials, relief of sore throat pain with 20 mg ambroxol was significantly greater than placebo starting at 30
minutes after dosing and lasting at least three hours [33]. Treatment was well tolerated, though
numbness of the tongue/oral cavity and changes in taste perception were noted, particularly in patients
with less severe sore throat at baseline. Lozenges containing ambroxol are not available in the United
States.

● AMC/DCBA for acute sore throat due to upper respiratory tract infection were evaluated in two industry-
sponsored randomized controlled trials in the United Kingdom [34,35]. Compared with placebo,
AMC/DCBA was associated with a decrease in throat soreness starting within five minutes of use and
persisting at two hours.

● Flurbiprofen, a nonsteroidal antiinflammatory drug (NSAID) marketed in a lozenge available in the

European Economic Area and not available in the United States, showed efficacy in a number of
industry-sponsored randomized controlled trials [36-40].

Throat sprays — Throat sprays available over-the-counter can provide rapid relief of acute sore throat pain.
The active ingredients generally include phenol, benzocaine, or chlorhexidine gluconate and benzydamine
hydrochloride. Throat sprays may be more cumbersome to use than lozenges. Data on the efficacy of throat
sprays are limited.

Phenol is the active ingredient in many over-the-counter throat sprays marketed in the United States for relief
of sore throat pain. Phenol is described to have both antiseptic and anesthetic properties. Phenol sprays
have not been rigorously studied in clinical trials, although there is some in vitro evidence that certain topical
antiseptics may block neuronal sodium channels to exert local anesthetic effects in sore throat treatment [41].

Benzocaine spray can be effective at alleviating the pain of sore throat; however, it carries a risk of
methemoglobinemia. The FDA issued a public health advisory regarding this risk associated with benzocaine
sprays, and the agency continues to receive reports of the occurrence of methemoglobinemia.

One well-studied spray that contains chlorhexidine gluconate (a topical antiseptic) and benzydamine
hydrochloride (a topical antiinflammatory) and is not available in the United States reduced sore throat pain
and was well tolerated in patients with acute viral or streptococcal pharyngitis in two randomized controlled
trials [42,43]. An herbal spray of echinacea and sage was as effective as a spray containing chlorhexidine
and lidocaine for relief of sore throat pain in a randomized trial from Switzerland [44]. Neither product is
available in the United States.

Fluids, herbs, and foods for sore throat relief — Adjusting the temperature and texture of foods and
beverages may provide local relief of sore throat pain. While data showing benefit are quite limited, these
approaches are intuitive. We typically advise these measures since they are likely to be safe with minimal
adverse effect, and patients often describe relief of symptoms.

We suggest hydration with frozen (eg, ice or popsicles) or heated liquids (eg, teas, soups), rather than room
temperature or refrigerated fluids in patient with significant sore throat pain. Very cold foods can have a

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numbing-like effect that temporarily reduces or alleviates the pain of swallowing. Ice cubes or frozen
popsicles facilitate hydration; ice cream and frozen yogurt provide caloric intake.

Warm fluids and foods, including teas, soups, and soft non-irritating foods, may be better tolerated by
patients with throat pain than irritating foods (eg, rough-textured or spicy foods) or fluids at room
temperatures. Foods that coat the throat, including honey and hard candies, can facilitate intake of calories
while temporarily relieving throat pain.

Many teas and herbal drops are marketed in the United States for relief of sore throat pain; this is supported
by a weak evidence base. These products may contain agents identified as demulcents, which have
mucilaginous effects purported to relieve oral and pharyngeal mucosal irritation by forming a soothing film
over mucous membranes. Commonly used demulcents in such products include honey, pectin, and glycerin.

A small multicenter industry-sponsored randomized controlled trial of an herbal tea containing licorice root,
elm inner bark, marshmallow root, and licorice root aqueous dry extract (Throat Coat) was performed in 60
adult patients presenting to clinics in the United States with acute pharyngitis. The tea was found to
significantly diminish sore throat pain compared with placebo during the 30 minutes after drinking, with no
serious adverse events [45].

HELPFUL ENVIRONMENTAL APPROACHES — Nonpharmacologic therapies as adjuncts to oral systemic

and topical treatments could help relieve symptoms by limiting throat irritants, although there are few data to
support their use. Benefits include ready availability and low cost of administration.

● Humidifying the environment to avoid excessive dryness can be achieved through use of humidifiers,
which need to be cleaned regularly to avoid spreading harmful mold or bacteria. Humidification can also
be achieved by spending a few minutes in a closed bathroom with a warm shower running and repeating
that several times a day.

● Avoiding exposure to tobacco smoke, both by eliminating smoking and by staying away from
secondhand smoke, prevents irritation from smoke that can exacerbate sore throat pain.

THERAPIES OF UNCERTAIN BENEFIT — Therapies without definitively proven benefit include acupuncture
and Chinese medicinal herbs.

● Acupuncture was found in one study to be effective at lowering pain scores for sore throat, yet in another
study not to be more effective than a sham treatment [46,47].

● Chinese medicinal herbs for relief of pharyngitis have been studied; however, significant methodologic
flaws were found in 10 of 12 studies and moderate-quality evidence in two [48]. Some Chinese herbal
medicines were more effective than the comparators (other herbs, topical and systemic antibiotics in
individual studies) in individual studies; however, definitive conclusions could not be drawn due to the
lack of high-quality studies.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected
countries and regions around the world are provided separately. (See "Society guideline links: Streptococcal
tonsillopharyngitis".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics”
and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5th to 6th
grade reading level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer short, easy-to-
read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more
detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want
in-depth information and are comfortable with some medical jargon.

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Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail
these topics to your patients. (You can also locate patient education articles on a variety of subjects by
searching on “patient info” and the keyword(s) of interest.)

● Basics topics (see "Patient education: Sore throat in adults (The Basics)")

● Beyond the Basics topics (see "Patient education: Sore throat in adults (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Pain relief is one of the most important reasons for patient visits for acute pharyngitis. Contrary to
provider preconceptions, receiving an antibiotic prescription is not a top priority for patients seeking care.
Overtreatment of acute pharyngitis represents a major cause of inappropriate antibiotic use. (See
'General concepts' above.)

● In an effort to avoid unnecessary antibiotic prescriptions, we discuss the risks and benefits of antibiotic
and non-antibiotic approaches, including the value of non-antibiotic pain relief; validate patient’s goals
and concerns; educate them about the expected clinical course and time to improvement; and
emphasize open communication to bring worsening symptoms or lack or expected improvement to
attention. (See 'Avoid antibiotic overprescribing' above and "Antimicrobial stewardship in outpatient
settings", section on 'Education and expertise'.)

● Pain relief approaches for acute pharyngitis in adults include systemic oral analgesics, topical therapies,
and environmental measures. Considerations when choosing among them include patient factors (eg,
sore throat symptom severity, presence of concomitant symptoms, and any patient comorbidities) and
therapy-related factors (eg, rapidity of onset of action, duration of effective relief, and side effect profile of
each treatment) (see 'Approach to symptom control' above):

• For most patients, we suggest a systemic oral analgesic (eg, nonsteroidal antiinflammatory drug
[NSAID], acetaminophen, aspirin) rather than topical therapies (Grade 2C). NSAIDs,
acetaminophen, and aspirin have all been shown to provide sore throat pain relief; ibuprofen
appears to be somewhat more effective than acetaminophen, although it is uncertain if the efficacy
benefit is clinically meaningful in treating pharyngitis. The choice among them depends on patient
preference after taking into account the side effect profile of the treatment(s) in the context of the
patient’s comorbidities. (See 'Systemic oral therapies' above.)

• Topical therapies alone are a reasonable alternative for patients who want to avoid systemic therapy
or are at higher risk for side effects from it, but their duration of effectiveness is shorter than for
systemic therapies. It is also reasonable to use topical therapies in combination with systemic
therapy. Topical therapies in the form of lozenges or sprays have the advantages of direct
application to the affected throat area, rapid onset of action, and minimal toxicity risk. It may also be
helpful for patients to consume warm fluids, teas with honey, and soups and to let ice chips or
popsicles melt in their mouth. (See 'Therapies applied topically to the throat' above.)

• We suggest not using glucocorticoids on a routine basis for the relief of pain associated with an
acute sore throat (Grade 2C). We restrict their use to the exceptional patient who presents with
severe throat pain and the inability to swallow. Glucocorticoids modestly reduce the duration of
throat pain; however, other analgesic agents (eg, NSAIDs, acetaminophen, aspirin) are also
effective and carry less risk of toxicity. (See 'Limited role of glucocorticoids' above.)

● If patients use more than one pharmacologic therapy, they should be cognizant of active ingredients in
the preparations to avoid exceeding the recommended dose of any ingredient. (See 'Approach to
symptom control' above.)

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