Diagnosis of a sore throat does not mean that an antibiotic has to be administered (see section 5). Adequate analgesia will usually be all that is required.

4.1 Simple Analgesics

The majority of patients with sore throat probably never attend a general practitioner and obtain symptomatic relief with aspirin or paracetamol. The recognised complications of aspirin therapy, including Reye's syndrome in children, make this agent less suitable for general use.

4.2 Non-Steroidal Anti-Inflammatory Agents

Several reports describe the use of non-steroidal anti-inflammatory agents (NSAIDs) in acute pharyngitis and tonsillitis.^33-35 These originate in France, where the drug is used in suppository form. The studies suggest that between two and three days after the start of treatment there is slightly faster resolution of pain, fever, dysphagia, visible inflammation, and lymphadenopathy compared with either placebo or paracetamol. All patients in these studies were given concomitant phenoxymethylpenicillin. The benefits of NSAIDs over paracetamol or placebo were short lived, as the symptoms of acute pharyngitis and tonsillitis tend to diminish quickly during the first 48-72 hours. Evidence level Ib

NSAIDs are associated with well recognised risks, such as gastrointestinal bleeding, nausea, vomiting, abdominal pain, and diarrhoea.

Taking account of the increased risks associated with NSAIDs, their routine use is not recommended. Extrapolated from evidence level Ib

4.3 Other Analgesics

There is minimal literature regarding the use of stronger analgesics for sore throat. Combination preparations (such as paracetamol with codeine) are known to be associated with nausea, disorientation and severe constipation, but may be useful for some patients. In hospital and in general practice weak opioids such as dihydrocodeine, sometimes in combination with other agents, are occasionally used but the risks of abuse limit their value in general practice.

There is no convincing evidence that analgesics other than paracetamol are routinely necessary in acute sore throat.

Paracetamol is the drug of choice for analgesia in sore throat, taking account of the increased risks associated with other analgesics.

4.4 Adjunctive Therapy

Benzydamine hydrochloride (Difflam) as an oral rinse or spray is sometimes used. One small study³⁶ showed that benzydamine as a gargle for sore throat resulted in significantly greater relief of pain and dysphagia at 24 hours than placebo, but this requires confirmation. Evidence level Ib

Corticosteroids are very occasionally prescribed in hospital in patients with acute infectious mononucleosis when pain and swelling threaten the airway or where there is very severe dysphagia.

4.5 Symptomatic treatment in the community

The local pharmacist is a useful source of advice on management of uncomplicated sore throat in the community.