Analgesics
Place in Therapy
Place in therapy (Children)
There are limited studies looking at treatment for acute sore throat in children. In this population, there are three commercially available treatment options (available in Canada) that have shown to provide symptomatic relief of acute sore throat. These include ibuprofen, acetaminophen, and phenol.
An early study evaluated the effectiveness of either ibuprofen or acetaminophen for treating pain associated with sore throat in children (6-12 years of age) <1>. Acute sore throat pain was reduced with ibuprofen and acetaminophen. However, ibuprofen was significantly better than acetaminophen for reducing pain and pain associated with swallowing. A newer study with same age group supports the use of acetaminophen syrup for treatment of sore throat.2 In these trials, no major adverse effects were reported <1,2>.
One study evaluated phenol including patients 7 years of age.3 Although a sub-analysis for children was not performed, the overall benefits favored the use of phenol for treatment of acute sore throat <3>.
Based on the available evidence, ibuprofen demonstrates the ability to reduce acute sore throat pain in children. However, non-steroidal anti-inflammatory drugs (NSAIDs) are generally associated with more adverse effects compared to acetaminophen. If a safer option is desired, acetaminophen can also improve acute sore throat pain. Phenol represents a therapeutic alternative that can be considered if patients cannot tolerate ibuprofen or acetaminophen.
References
1. Bertin L, Pons G, d’Athis P, Lasfargues G, Maudelonde C, Duhamel JF, Olive G. Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. J Pediatr 1991; 119:811-14.
2. Ruperto N, Carozzino L, Jamone R, Freschi F, Picollo G, Zera M, Della Casa Alberighi O, Salvatori E, Del Vecchio A, Dionisio P, Martini A. A randomized, double-blind, placebo-controlled trial of paracetamol and ketoprofen lysine salt for pain control in children with pharyngotonsillitis cared by family pediatricians.
3. Valle-Jones JC. Chloraseptic liquid in sore throat. The Practitioner 1983;227:1037-1040.
Place in therapy (Adults)
Many clinical trials have evaluated the role of acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) in providing sore throat pain relief associated with upper respiratory tract infection (URTI).
An early study evaluated the effect of NSAIDs for treating pain associated with sore throat in adults <1>. In this study, ibuprofen was shown to reduce subjective measures of pain to a greater extent compared to acetaminophen <1>. However, both analgesics provided greater relief compared to placebo <1>. Newer studies also suggest that ibuprofen provides greater analgesic relief for sore throat compared to acetaminophen <2>.
More recently, four randomized control trials (RCTs) evaluated the efficacy and safety of flurbiprofen lozenges used to treat sore throat secondary to URTI <3,4>. These RCTs support the use of flurbiprofen lozenges for temporary (up to 6 hours) relief of sore throat <3,4>. Flurbiprofen lozenges supplied at either 8.75mg or 12.5mg improved patient outcomes associated with sore throat <3,4>. More importantly, no adverse effects were reported with the use of flurbiprofen in these studies <3,4>. Tthe only studies with NSAID lozenges involve flurbiprofen. Furibiprofen is not available in Canada. Compared to ibuprofen, flurbiprofen appears to a more potent analgesic <5>. As such, recommendation of NSAID lozenges should be made with caution by healthcare professionals.
Acetylsalicylic acid (ASA) was examined as a therapeutic agent for acute sore throat in several studies. The earliest trial showed relief of acute sore throat with ASA (800mg) alone or in combination with caffeine (64mg).6 However, there was no statistical difference between the two treatment arms <6>. Thus, ASA alone or in combination with caffeine can provide symptomatic improvement of acute sore throat <6>. A systematic review showed caffeine as monotherapy can be used for pain reduction however; the source of pain was not specific to sore throat <7>. In one study, acetylsalicylic acid (ASA) effervescent tablets were used in patients experiencing sore throat associated with URTI <6>. ASA 800mg was found improve symptoms associated with sore throat <8>. In Canada, only ASA 325mg effervescent tablets are available. The investigators of this study prepared ASA 800 mg in 6 ounces of water (approximate concentration of 4.4 mg/ml) <8>. No adverse effects were reported with taking ASA 800mg up to three days <8>.
How to pick the appropriate analgesic for adult patients?
The evidence suggests all oral analgesics described above provide benefits over placebo. The only published guidelines available for management of acute sore throat was created by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) <9>. The ESCMID guidelines specifically recommends the use of ibuprofen or acetaminophen <9>. However, the ESCMID guidelines recognizes the positive results of ASA in one trial <8,9>. In comparative trials, NSAIDs provided better acute sore throat pain relief compared to acetaminophen <1,2>. There was one comparative trial that examined the effectiveness of ASA or acetaminophen for treating fever and upper respiratory tract infections (URTI) <10>. This trial looked at sore throat as a secondary outcome <10>. There was no improvement in sore throat pain with either aspirin or acetaminophen <10>. However, based on the other studies <6,8>, aspirin or acetaminophen can still be considered as therapeutic alternatives for treatment of sore throat.
Analgesic doses used in clinical trials
Doses used in clinical trials for adults:
Ibuprofen (oral tablets): 400 mg
ASA (effervescent tablets): 800 mg in 6 ounces of water
ASA (oral tablets): 800 mg
ASA + Caffeine: ASA 800 mg; Caffeine 64 mg
Acetaminophen: 500 – 1000 mg
Doses used in clinical trials for children:
Ibuprofen: 10 mg/kg
Acetaminophen: 10-12 mg/kg
The choice depends on patient preference. Patient considerations include co-morbidities, cost and convenience. Patients with underlying renal dysfunction and/or bleeding risks are encouraged to avoid NSAIDs. In these cases, acetaminophen would be the analgesic of choice for sore throat. If patients demonstrate concerns regarding cost, oral analgesics are preferred over NSAID lozenges. NSAID lozenges are not commercially available in Canada. Patients would need to get NSAID lozenges compounded at specialized pharmacies. More importantly, the active pharmaceutical ingredient (API) involved in trials evaluating NSAID lozenges is not available in Canada. Healthcare professionals will need to discuss the risks and benefits of using NSAIDs available in Canada as lozenge dosage forms. Overall, the clinical trials evaluated these analgesics independently over a short time frame (ranging from 6 hours to 5 days). Thus, healthcare professionals need to use professional judgement for patients that experience treatment failure with any of these therapeutic options.
References
1. Schachtel BP, Fillingim JM, Thoden WR, Lane AC, Baybutt RI. Sore throat pain in the evaluation of mild analgesics. Clin Pharmacol Ther 1988; 44(6):704-11.
2. Boureau F, Pelen F, Verriere F, Paliwoda A, Manfredi R, Farhan M. Evaluation of ibuprofen vs paracetamol analgesic activity using a sore throat pain model. Clin Drug Investig 1999; 17(1):1-8.
3. Benrimoj SI, Langford JH, Christian J, Charlesworth A, Steans A. Efficacy and tolerability of the anti-inflammatory throat lozenge flurbiprofen 8.75mg in the treatment of sore throat. Clin Drug Invest 2001; 21(3):183-193.
4. Schachtel BP, Homan HD, Gibb IA, Christian J. Demonstration of dose response of flurbiprofen lozenges with the sore throat pain model. Clin Pharmacol Ther 2002; 71:375-80.
5. Kantor TG. Physiology and treatment of pain and inflammation – analgesic effects of flurbiprofen.Am J Med.1986; 80(Suppl 3A):3-9.
6. Schachtel BP, Fillingim JM, Lane AC, Thoden W, Baybutt RI. A double-blind study comparing aspirin with caffeine to aspirin and placebo in patients with sore throat. Arch Intern Med 1991;151:733-737.
7. Derry CJ, Derry S, Moore RA. Caffeine as an analgesic adjuvant for acute pain in adults. Cochrane database of systematic reviews 2012, Issue 5.
8. Eccles R, Loose I, Jawad, M, Nyman L. Effects of acetylsalicylic acid on sore throat pain and other pain symptoms associated with acute upper respiratory tract infection. Pain Med 2003; 4(2):118-124.
9. Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, Verhij V. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 (Suppl. 1):1-27.
10. Bachert C, Chuchalin AG, Eisebitt R, Netayzhenko VZ, Voelker M. Aspirin compared with acetaminophen in the treatment of fever and other symptoms of upper respiratory tract infection in adults: a multicenter, randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-dose, 6-hour dose-ranging study. Clin Ther 2005; 27(7):993-1003.
There are limited studies looking at treatment for acute sore throat in children. In this population, there are three commercially available treatment options (available in Canada) that have shown to provide symptomatic relief of acute sore throat. These include ibuprofen, acetaminophen, and phenol.
An early study evaluated the effectiveness of either ibuprofen or acetaminophen for treating pain associated with sore throat in children (6-12 years of age) <1>. Acute sore throat pain was reduced with ibuprofen and acetaminophen. However, ibuprofen was significantly better than acetaminophen for reducing pain and pain associated with swallowing. A newer study with same age group supports the use of acetaminophen syrup for treatment of sore throat.2 In these trials, no major adverse effects were reported <1,2>.
One study evaluated phenol including patients 7 years of age.3 Although a sub-analysis for children was not performed, the overall benefits favored the use of phenol for treatment of acute sore throat <3>.
Based on the available evidence, ibuprofen demonstrates the ability to reduce acute sore throat pain in children. However, non-steroidal anti-inflammatory drugs (NSAIDs) are generally associated with more adverse effects compared to acetaminophen. If a safer option is desired, acetaminophen can also improve acute sore throat pain. Phenol represents a therapeutic alternative that can be considered if patients cannot tolerate ibuprofen or acetaminophen.
References
1. Bertin L, Pons G, d’Athis P, Lasfargues G, Maudelonde C, Duhamel JF, Olive G. Randomized, double-blind, multicenter, controlled trial of ibuprofen versus acetaminophen (paracetamol) and placebo for treatment of symptoms of tonsillitis and pharyngitis in children. J Pediatr 1991; 119:811-14.
2. Ruperto N, Carozzino L, Jamone R, Freschi F, Picollo G, Zera M, Della Casa Alberighi O, Salvatori E, Del Vecchio A, Dionisio P, Martini A. A randomized, double-blind, placebo-controlled trial of paracetamol and ketoprofen lysine salt for pain control in children with pharyngotonsillitis cared by family pediatricians.
3. Valle-Jones JC. Chloraseptic liquid in sore throat. The Practitioner 1983;227:1037-1040.
Place in therapy (Adults)
Many clinical trials have evaluated the role of acetaminophen and/or non-steroidal anti-inflammatory drugs (NSAIDs) in providing sore throat pain relief associated with upper respiratory tract infection (URTI).
An early study evaluated the effect of NSAIDs for treating pain associated with sore throat in adults <1>. In this study, ibuprofen was shown to reduce subjective measures of pain to a greater extent compared to acetaminophen <1>. However, both analgesics provided greater relief compared to placebo <1>. Newer studies also suggest that ibuprofen provides greater analgesic relief for sore throat compared to acetaminophen <2>.
More recently, four randomized control trials (RCTs) evaluated the efficacy and safety of flurbiprofen lozenges used to treat sore throat secondary to URTI <3,4>. These RCTs support the use of flurbiprofen lozenges for temporary (up to 6 hours) relief of sore throat <3,4>. Flurbiprofen lozenges supplied at either 8.75mg or 12.5mg improved patient outcomes associated with sore throat <3,4>. More importantly, no adverse effects were reported with the use of flurbiprofen in these studies <3,4>. Tthe only studies with NSAID lozenges involve flurbiprofen. Furibiprofen is not available in Canada. Compared to ibuprofen, flurbiprofen appears to a more potent analgesic <5>. As such, recommendation of NSAID lozenges should be made with caution by healthcare professionals.
Acetylsalicylic acid (ASA) was examined as a therapeutic agent for acute sore throat in several studies. The earliest trial showed relief of acute sore throat with ASA (800mg) alone or in combination with caffeine (64mg).6 However, there was no statistical difference between the two treatment arms <6>. Thus, ASA alone or in combination with caffeine can provide symptomatic improvement of acute sore throat <6>. A systematic review showed caffeine as monotherapy can be used for pain reduction however; the source of pain was not specific to sore throat <7>. In one study, acetylsalicylic acid (ASA) effervescent tablets were used in patients experiencing sore throat associated with URTI <6>. ASA 800mg was found improve symptoms associated with sore throat <8>. In Canada, only ASA 325mg effervescent tablets are available. The investigators of this study prepared ASA 800 mg in 6 ounces of water (approximate concentration of 4.4 mg/ml) <8>. No adverse effects were reported with taking ASA 800mg up to three days <8>.
How to pick the appropriate analgesic for adult patients?
The evidence suggests all oral analgesics described above provide benefits over placebo. The only published guidelines available for management of acute sore throat was created by the European Society for Clinical Microbiology and Infectious Diseases (ESCMID) <9>. The ESCMID guidelines specifically recommends the use of ibuprofen or acetaminophen <9>. However, the ESCMID guidelines recognizes the positive results of ASA in one trial <8,9>. In comparative trials, NSAIDs provided better acute sore throat pain relief compared to acetaminophen <1,2>. There was one comparative trial that examined the effectiveness of ASA or acetaminophen for treating fever and upper respiratory tract infections (URTI) <10>. This trial looked at sore throat as a secondary outcome <10>. There was no improvement in sore throat pain with either aspirin or acetaminophen <10>. However, based on the other studies <6,8>, aspirin or acetaminophen can still be considered as therapeutic alternatives for treatment of sore throat.
Analgesic doses used in clinical trials
Doses used in clinical trials for adults:
Ibuprofen (oral tablets): 400 mg
ASA (effervescent tablets): 800 mg in 6 ounces of water
ASA (oral tablets): 800 mg
ASA + Caffeine: ASA 800 mg; Caffeine 64 mg
Acetaminophen: 500 – 1000 mg
Doses used in clinical trials for children:
Ibuprofen: 10 mg/kg
Acetaminophen: 10-12 mg/kg
The choice depends on patient preference. Patient considerations include co-morbidities, cost and convenience. Patients with underlying renal dysfunction and/or bleeding risks are encouraged to avoid NSAIDs. In these cases, acetaminophen would be the analgesic of choice for sore throat. If patients demonstrate concerns regarding cost, oral analgesics are preferred over NSAID lozenges. NSAID lozenges are not commercially available in Canada. Patients would need to get NSAID lozenges compounded at specialized pharmacies. More importantly, the active pharmaceutical ingredient (API) involved in trials evaluating NSAID lozenges is not available in Canada. Healthcare professionals will need to discuss the risks and benefits of using NSAIDs available in Canada as lozenge dosage forms. Overall, the clinical trials evaluated these analgesics independently over a short time frame (ranging from 6 hours to 5 days). Thus, healthcare professionals need to use professional judgement for patients that experience treatment failure with any of these therapeutic options.
References
1. Schachtel BP, Fillingim JM, Thoden WR, Lane AC, Baybutt RI. Sore throat pain in the evaluation of mild analgesics. Clin Pharmacol Ther 1988; 44(6):704-11.
2. Boureau F, Pelen F, Verriere F, Paliwoda A, Manfredi R, Farhan M. Evaluation of ibuprofen vs paracetamol analgesic activity using a sore throat pain model. Clin Drug Investig 1999; 17(1):1-8.
3. Benrimoj SI, Langford JH, Christian J, Charlesworth A, Steans A. Efficacy and tolerability of the anti-inflammatory throat lozenge flurbiprofen 8.75mg in the treatment of sore throat. Clin Drug Invest 2001; 21(3):183-193.
4. Schachtel BP, Homan HD, Gibb IA, Christian J. Demonstration of dose response of flurbiprofen lozenges with the sore throat pain model. Clin Pharmacol Ther 2002; 71:375-80.
5. Kantor TG. Physiology and treatment of pain and inflammation – analgesic effects of flurbiprofen.Am J Med.1986; 80(Suppl 3A):3-9.
6. Schachtel BP, Fillingim JM, Lane AC, Thoden W, Baybutt RI. A double-blind study comparing aspirin with caffeine to aspirin and placebo in patients with sore throat. Arch Intern Med 1991;151:733-737.
7. Derry CJ, Derry S, Moore RA. Caffeine as an analgesic adjuvant for acute pain in adults. Cochrane database of systematic reviews 2012, Issue 5.
8. Eccles R, Loose I, Jawad, M, Nyman L. Effects of acetylsalicylic acid on sore throat pain and other pain symptoms associated with acute upper respiratory tract infection. Pain Med 2003; 4(2):118-124.
9. Pelucchi C, Grigoryan L, Galeone C, Esposito S, Huovinen P, Little P, Verhij V. Guideline for the management of acute sore throat. Clin Microbiol Infect 2012; 18 (Suppl. 1):1-27.
10. Bachert C, Chuchalin AG, Eisebitt R, Netayzhenko VZ, Voelker M. Aspirin compared with acetaminophen in the treatment of fever and other symptoms of upper respiratory tract infection in adults: a multicenter, randomized, double-blind, double-dummy, placebo-controlled, parallel-group, single-dose, 6-hour dose-ranging study. Clin Ther 2005; 27(7):993-1003.