From the Guidelines
Changing from meloxicam to prednisone for lumbago with sciatica is not typically recommended as a first-line approach. It's better to continue meloxicam (an NSAID) as it specifically targets inflammation at the site of nerve compression with fewer systemic side effects than prednisone. If the patient isn't experiencing adequate relief after 2-3 weeks on an appropriate meloxicam dose (typically 7.5-15mg daily), consider adding physical therapy, muscle relaxants like cyclobenzaprine (5-10mg TID), or gabapentinoids such as gabapentin (starting at 300mg daily and titrating up) rather than switching to prednisone. Prednisone carries significant side effects including mood changes, insomnia, increased blood glucose, and bone density loss, making it more appropriate as a short-term rescue therapy (typically 20mg daily for 5-7 days with a taper) for severe, acute exacerbations rather than routine management. Before changing medication, reassess the patient for red flags requiring imaging or specialist referral, such as progressive neurological deficits, saddle anesthesia, or bowel/bladder dysfunction. According to the American College of Physicians and the American Pain Society guidelines 1, systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, because they have not been shown to be more effective than placebo.
Some key points to consider when managing lumbago with sciatica include:
- Continuing meloxicam as the first-line treatment for its targeted anti-inflammatory effects
- Adding non-pharmacologic therapies such as physical therapy or exercise for patients not improving with self-care options
- Considering alternative pharmacologic options like muscle relaxants or gabapentinoids for inadequate relief
- Avoiding systemic corticosteroids due to lack of efficacy and potential side effects
- Monitoring for red flags that may necessitate further evaluation or specialist referral.
From the Research
Patient with Lumbago and Sciatica on Meloxicam
- The patient is currently taking meloxicam for lumbago with sciatica, and the question is whether to change the prescription to prednisone.
- According to the studies, meloxicam has been shown to be effective in treating acute sciatica 2 and lumbago 3.
- In one study, meloxicam was found to be as effective as diclofenac in acute sciatica, with significant improvements in overall pain and functional activity 2.
- Another study compared the efficacy and tolerability of intramuscular and oral meloxicam with piroxicam in patients with acute lumbago, and found that meloxicam had a rapid onset of action and was well tolerated, with fewer gastrointestinal adverse events than piroxicam 3.
- There is no direct evidence to suggest that prednisone is more effective than meloxicam in treating lumbago with sciatica.
- However, it is worth noting that meloxicam is a nonsteroidal anti-inflammatory drug (NSAID) with a selective inhibitor of cyclooxygenase-2 (COX-2), and its use may be associated with an increased risk of serious gastrointestinal adverse events, including ulceration and bleeding 4.
- The decision to change the prescription to prednisone should be based on the patient's individual response to meloxicam and the presence of any adverse events or contraindications.
- It may be beneficial to consider alternative treatment options, such as physical therapy or other NSAIDs, in addition to or instead of prednisone, depending on the patient's specific needs and medical history.