EVIDENCE-BASED ANSWER
NONSTEROIDAL ANTI-INFLAMMATORY DRUGS (NSAIDs), acetaminophen, antibiotics, and oral and intramuscular steroids are effective (strength of recommendation [SOR]: A, meta-analysis).
Ibuprofen relieves pain more effectively than acetaminophen (SOR: A, meta-analysis). Antibiotics reduce pain in confirmed bacterial infections (SOR: A, multiple randomized controlled trials [RCTs]). Steroids are superior to placebo (SOR: A, meta-analysis).
Traditional demulcents, agents that help form a film over mucous membranes, provide less than 30 minutes of pain relief (SOR: B, small RCT); demulcents that contain benzocaine or lidocaine are longer acting (SOR: B, small RCT).
The efficacy of herbal remedies can’t be determined because of lack of high-quality studies (SOR: A, meta-analysis). Zinc doesn’t reduce pharyngitis symptoms (SOR: A, meta-analysis).
Evidence summary
A meta-analysis of 54 RCTs that investigated pain control, 5 of which focused on pharyngitis, showed that both ibuprofen and acetaminophen are more effective than placebo.1 In the 3 adult RCTs (N=346) and 2 pediatric RCTs (N=347) that studied pharyngitis specifically, 400 mg ibuprofen 3 times a day (10 mg/kg in children) provided more pain relief than 1000 mg acetaminophen 3 times a day (15 mg/kg in children).1
One of the RCTs, a double-blind, single-dose, single-center study of pharyngitis, found that 400 mg ibuprofen reduced pain by 80% at 3 hours compared with a 50% decrease for 1000 mg acetaminophen (P<.01).2 At 6 hours, ibuprofen still produced 70% relief compared with 20% for acetaminophen (P<.01). The meta-analysis demonstrated no significant difference in side effects between the 2 drugs.1
Steroids help, but concomitant antibiotics muddy the data
A meta-analysis of 8 RCTs enrolling 743 patients (369 children and 374 adults) found that oral and intramuscular steroids reduce duration and intensity of pain in moderate to severe pharyngitis and exudative pharyngitis.3 Four of the studies showed that corticosteroids completely resolve pain at 24 hours compared with placebo (number needed to treat [NNT]=3.7; 95% confidence interval [CI], 2.8-5.9), and 3 studies demonstrated pain relief at 48 hours (NNT=3.3; 95% CI, 2.4-5.6).
Although time to pain resolution varied among the studies, the research demonstrated a decrease in mean onset of pain relief by 6 hours compared with placebo (95% CI, 3.4-9.3; P<.001).3 All of the studies in the meta-analysis were limited by the fact that steroids were given in combination with antibiotics.
Demulcents have short-lived effect with a boost from anesthetics
A multicenter, prospective, randomized, double-blinded, placebo-controlled study (N=60) showed that demulcents provide short-term pain relief. On combined self-reported pain scales at 5, 10, 15, and 30 minutes, herbal tea demulcents were more effective than placebo (mean improvement in overall pain score=66.7 ± 39.2 on a 150-point scale, compared with 48.7 ± 32.8; P=.031). No difference was seen after 30 minutes.4
Demulcents with added anesthetics provide superior pain relief compared to placebo, as measured on a visual analog scale. In a single-center, randomized, double-blinded, placebo-controlled phase III study (N=240), patients who reported meaningful pain relief with lidocaine lozenges compared with placebo showed benefit from both single doses (38.3% lozenges vs 11.7% placebo; NNT=3.8) and multiple doses (73.3% lozenges vs 34.2% placebo; NNT=2.5). Additionally, pain relief lasted for >2 hours per lozenge. They also experienced more rapid onset of relief (24 minutes on average compared with 41 minutes).5
Antibiotics work better in patients with strep
A Cochrane review comparing antibiotics with placebo for sore throat showed an NNT of 5.8 (relative risk [RR]=0.68; 95% CI, 0.59-0.79) for pain resolution by Day 3 and an NNT of 21 (RR=0.49; 95% CI, 0.32-0.76) for pain resolution by Day 7. Antibiotics reduced pain more effectively in patients who tested positive for Streptococcus (RR=0.58; 95% CI, 0.48-0.71) than patients who tested negative (RR=0.78; 95% CI 0.63-0.97).6