Corticosteroids for infectious mononucleosis

Treatment

Once a diagnosis has been made clinically or through laboratory testing, treatment of IM includes rest, enhancing hydration, and addressing fever and pharyngitis. Pharmacologic options include nonsteroidal anti-inflammatory drugs, acetaminophen, and throat lozenges or sprays containing anesthetics such as benzocaine, phenol, or lidocaine.^7,8

Antiviral medications such as acyclovir and valacyclovir have been shown to provide little to no symptom alleviation.^9,10 Combinations of prednisone and acyclovir have similarly shown overall varying to little effect.¹¹

Corticosteroid use in IM

Corticosteroids exert anti-inflammatory properties through interactions with inflammatory genes. Specifically, after binding with receptors, responsive elements alter inflammatory gene expression, which affects cytokines, chemokines, adhesion molecules, and inflammatory enzymes.¹² Corticosteroids as anti-inflammatory agents are recommended for patients with severe complications of IM such as airway obstruction, autoimmune hemolytic anemia, and thrombocytopenia.¹³ Their use for symptom relief is not considered standard and has been shown to have varying degrees of efficacy.^7,8

A Cochrane review examined 7 randomized controlled trials with a total of 362 participants with IM between 14 and 30 years old.¹⁴ Two trials found corticosteroid treatment to be somewhat effective in alleviating pain from pharyngitis.^15,16 In a study of 24 participants from Indiana University in the United States,¹⁵ Klein et al found a 10-mg starting dose of prednisolone or cortisone (tapered over 8 days) was associated with reduction of pain owing to pharyngitis at 12 hours (odds ratio [OR]=21.0, 95% CI 1.94 to 227.20) but not at 36 hours (OR=6.0, 95% CI 1.02 to 35.37).¹⁴ In a trial from Montréal, Que,¹⁶ Roy et al found that more children between 8 and 18 years old who received 0.3 mg/kg (up to 15 mg) of dexamethasone shortly after diagnosis in the emergency department reported relief of pain owing to pharyngitis at 12 hours compared with those who received placebo (OR=4.2, 95% CI 1.08 to 16.32) but not at 24 hours (OR=2.85, 95% CI 0.78 to 10.47).¹⁴ Corticosteroids combined with antiviral drugs have also shown minimal effect. In a study of 94 patients between 14 and 29 years old in Sweden and the United Kingdom,¹¹ Tynell et al found that 800 mg of oral acyclovir taken 5 times a day with 0.7 mg/kg prednisolone for 4 days (reduced by 0.1 mg/kg for 6 additional days) resulted in a reduction of pain owing to pharyngitis compared with placebo from days 2 to 4 (OR=0.31, 95% CI 0.09 to 1.08) but not at 14 days, when no patients experienced pain owing to pharyngitis.¹⁴

In another trial from the United Kingdom, Bolden compared the effects of prednisone and acetylsalicylic acid on fever in 38 university students.¹⁷ The study used 2 prednisone regimens: 10 mg taken 4 times daily on days 1 and 2 reduced by 10 mg every 2 days until day 7, after which patients took 5 mg 3 times daily, tapered by 5 mg every 2 days until day 12; and 5 mg taken 4 times daily, tapered by 5 mg every 2 days until day 7, after which a placebo (lactose) was taken until day 12. There was no significant reduction in fever during the 6-day corticosteroid course, but a noticeable reduction was noted with the 12-day course (P=.05).^14,17 Finally, in a study of 82 students between 14 and 30 years old at Harvard University in Cambridge, Mass, and Princeton University in New Jersey,¹⁸ treatment with 2 mg of paramethasone taken orally (with the initial dose described as 8 tablets), tapered by 1 tablet per day upon symptom improvement, produced different results at each centre.¹⁴ Among the Harvard students, fever lasted an average of 1.99 and 3.7 days in the treatment and control groups, respectively; among the Princeton students, fever lasted 12.8 and 8.2 days in the treatment and control groups.¹⁴

In 4 of the 7 studies analyzed in the Cochrane review,¹⁴ no significant differences in symptom outcomes such as fever, pharyngitis, fatigue, or anorexia were reported with corticosteroid use.^17-20 Bolden, who studied the effects of 6- and 12-day courses of oral prednisone in 38 patients,¹⁷ found no difference in psychiatric score and found a reduction in fever only with the 12-day course (mean difference −3.89, 95% CI −7.05 to −0.73).¹⁴ Collins et al studied the use of 60 mg of oral prednisolone (N=47) among patients 18 to 28 years old with IM.¹⁹ In evaluating fatigue, anorexia, difficulty swallowing, excessive pharyngeal secretions, concentration difficulties, decreased social activity, and loss of class time, no significant differences were found at 1 or 4 weeks between the treatment and control groups.^14,19 Finally, a study by Simon et al²⁰ included participants 2 to 28 years old who received either prednisolone (1 mg/kg/day) or placebo, each with valacyclovir (20 mg/kg/dose), an antiviral medication.¹⁴ No significant differences were found between the treatment and control groups in the selected score for sore throat, swollen glands, fatigue, nausea, and chills or in a combined score including additional symptoms (selected OR=9.33, 95% CI 0.96 to 90.94; combined OR=2.00, 95% CI 0.38 to 10.51).^14,20