From the Guidelines
Prednisone should not be used as a first-line treatment for back pain, and its use should be limited to cases with significant inflammation or when other treatments have failed, at a dose of 20-60 mg daily for a short course of 5-7 days, due to the lack of evidence supporting its effectiveness in treating back pain and the potential for adverse effects 1. When considering the use of prednisone for back pain, it is essential to weigh the potential benefits against the risks, as the evidence suggests that systemic corticosteroids are not effective in treating acute nonradicular low back pain, spinal stenosis, or radicular low back pain of varying duration 1. The potential side effects of prednisone, such as increased risk of adverse events, insomnia, nervousness, and increased appetite, should also be taken into account, particularly at higher doses, as seen in the largest trial where oral prednisone (initial dose, 60 mg/d) increased the risk for any adverse event 1. In cases where prednisone is deemed necessary, patients should be closely monitored for potential side effects, and the medication should be used at the lowest effective dose for the shortest duration possible. Some key points to consider when prescribing prednisone for back pain include:
- Starting with a low dose and tapering as needed to minimize side effects
- Taking the medication in the morning with food to reduce gastrointestinal side effects and sleep disturbances
- Continuation of non-pharmacological approaches like physical therapy and appropriate exercise alongside medication treatment
- Caution in patients with diabetes, hypertension, or peptic ulcer disease due to the potential for prednisone to exacerbate these conditions.
From the Research
Steroid Dosing for Back Pain
The recommended dosing for prednisone in treating back pain is not well established, but some studies provide guidance on its use.
- For radicular low back pain, systemic corticosteroids may slightly decrease pain and improve function at short-term follow-up 2.
- The effects of systemic corticosteroids in people with non-radicular low back pain are unclear, and they are probably ineffective for spinal stenosis 2.
- A single dose or short course of systemic corticosteroids for low back pain does not appear to cause serious harms, but evidence is limited 2.
Dosage Recommendations
- One study suggests that low doses of prednisone (less than 10 mg/day) are safe and effective in managing rheumatoid arthritis, and that treatment should not exceed 10 mg/day 3.
- Another study found that prednisone at doses less than 5 mg/day over long periods appears acceptable and effective for many patients with rheumatoid arthritis 4.
- However, a randomized controlled trial found no benefit from oral corticosteroids in emergency department patients with musculoskeletal low back pain, with a dosage of 50 mg prednisone daily for 5 days 5.
Administration and Monitoring
- Epidural steroid injections are recommended in patients with signs and symptoms of nerve root irritation, and relief of pain is attributed to the anti-inflammatory effect of the steroid 6.
- Patients with acute radiculopathy have better response compared to patients with chronic symptoms, and improvement may not be noted until 6 days after the injection 6.
- The depression of the hypothalamic-pituitary-adrenal (HPA) axis lasts 3 weeks, and complications have been reported, although they are rare 6.