From the Guidelines
Oral glucocorticoids (GCs) should be used with caution in the treatment of lumbosciatalgia due to their potential for significant toxicity, including bone loss and fractures, as highlighted in the 2017 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis 1. When prescribed, a typical regimen might include prednisone 20mg daily for 5-7 days, potentially tapered over 10-14 days, though specific dosing protocols vary. Methylprednisolone dose packs (starting at 24mg and tapering over 6 days) are also commonly used. These medications work by reducing inflammation around compressed nerve roots, potentially decreasing pain and improving function temporarily. However, oral GCs carry significant side effect risks including:
- Mood changes
- Insomnia
- Increased blood glucose
- Fluid retention
- Bone density loss and adrenal suppression with longer use They should be used cautiously in patients with:
- Diabetes
- Hypertension
- Peptic ulcer disease
- Psychiatric conditions For most patients with lumbosciatalgia, first-line treatments should include:
- Non-steroidal anti-inflammatory drugs
- Physical therapy
- Activity modification with oral GCs reserved for those with severe symptoms who haven't responded to conservative measures and cannot tolerate other interventions. The risk of fracture associated with GC use is a significant concern, with more than 10% of patients who receive long-term GC treatment diagnosed with a clinical fracture, and 30–40% having radiographic evidence of vertebral fractures 1. Numerous risk calculators can be applied in clinical practice to provide estimates of risk of major OP fracture and hip fracture clinically diagnosed, with adjustment for GC dose in some but not all calculators 1. It is essential to identify those patients taking GCs for whom the benefits of preventive therapy sufficiently outweigh potential harms and to use the lowest effective dose for the shortest duration possible to minimize the risk of toxicity.
From the Research
Role of Oral Glucocorticoids in Lumbosciatalgia
- Oral glucocorticoids (GCs) have been used in the treatment of various inflammatory conditions, including rheumatic diseases 2.
- The therapeutic use of oral GCs in inflammatory rheumatic diseases involves the use of the smallest possible effective dose for the shortest possible time to achieve the desired therapeutic effect while minimizing the risk of severe side effects 2.
- In the context of lumbosciatalgia, the use of oral GCs has been explored as a potential treatment option, particularly for radicular low back pain 3.
- A systematic review of randomized controlled trials found that systemic corticosteroids, including oral GCs, may slightly decrease pain and improve function in patients with radicular low back pain at short-term follow-up 3.
- However, the evidence for the effectiveness of oral GCs in non-radicular low back pain and spinal stenosis is limited and unclear 3.
- The use of oral GCs in lumbosciatalgia is often considered in conjunction with other treatment options, such as physical therapy and epidural steroid injections 4.
- A randomized controlled trial found that epidural steroid injections and physical therapy were both effective in improving pain and functional parameters in patients with lumbar spinal stenosis, with no significant difference between the two treatment groups 4.
Key Findings
- Oral GCs may be effective in reducing pain and improving function in patients with radicular low back pain at short-term follow-up 3.
- The evidence for the effectiveness of oral GCs in non-radicular low back pain and spinal stenosis is limited and unclear 3.
- Oral GCs should be used at the smallest possible effective dose and for the shortest possible time to minimize the risk of severe side effects 2.
- The use of oral GCs in lumbosciatalgia should be considered in conjunction with other treatment options, such as physical therapy and epidural steroid injections 4.