Steroid Packs for Back Pain: Frequency Recommendations
Steroid packs (such as prednisone) should not be used routinely for back pain and should be limited to no more than 1-2 short courses per year due to significant risks of adverse effects with minimal evidence of benefit. 1, 2
Evidence on Efficacy for Back Pain
Non-Radicular Back Pain
- For acute non-radicular low back pain, systemic corticosteroids show no benefit over placebo for pain or function 1
- Two trials found no differences between a single intramuscular injection or a 5-day course of systemic corticosteroids and placebo 1
- A randomized controlled trial specifically found no benefit from oral corticosteroids in emergency department patients with musculoskeletal low back pain 3
Radicular Back Pain
- For radicular low back pain, systemic corticosteroids may provide only slight improvement in short-term pain (mean difference of 0.56 points on a 0-10 scale) 2
- Six trials consistently found minimal to no differences between systemic corticosteroids and placebo for pain relief in radicular back pain 1
- Function may be slightly improved in the short term, but effects are modest 2
Risks of Repeated Steroid Use
Short-term Adverse Effects
- Increased risk of any adverse event (49% vs. 24%) 1
- Common side effects include insomnia (26% vs. 10%), nervousness (18% vs. 8%), and increased appetite (22% vs. 10%) 1
- Hyperglycemia, especially in patients with diabetes 4
Long-term Risks with Repeated Use
- Hypothalamic-pituitary-adrenal (HPA) axis suppression lasting up to 3 weeks after a course 5
- Increased risk of glucocorticoid-induced osteoporosis, especially with cumulative doses ≥5g over 1 year 1
- Very high fracture risk with high-dose therapy (≥30 mg daily for ≥30 days) or cumulative dose ≥5g over 1 year 1
- Cushingoid state, growth suppression in children, and other metabolic effects 4
Recommended Approach to Steroid Use for Back Pain
When to Consider Steroids
- Reserve for severe, acute radicular pain that has not responded to other treatments 1, 2
- Not recommended for non-radicular back pain or spinal stenosis 1, 2
Dosing When Appropriate
- If used, a short course of prednisone (typically 5-7 days) is preferred 4
- Initial dose typically 1 mg/kg/day (maximum 60 mg/day) as a single morning dose 6
- Taper over 1-2 weeks rather than abrupt discontinuation 4
Frequency Limitations
- Limit to no more than 1-2 short courses per year 1
- For patients receiving multiple courses, consider the cumulative annual dose, which should remain below 5g per year to avoid very high fracture risk 1
Monitoring and Precautions
Before Repeat Courses
- Assess for adverse effects from previous courses 1
- Consider bone health if multiple courses are needed 1
- Evaluate for alternative treatments with better benefit-risk profiles 1
During Treatment
- Monitor for hyperglycemia, especially in diabetic patients 4
- Administer as a single morning dose to minimize HPA axis suppression 4
- Consider calcium (1000-1200 mg) and vitamin D (600-800 IU) supplementation during treatment 1
Alternative Approaches
- NSAIDs may be more appropriate for non-radicular back pain 1
- For inflammatory arthritis pain, consider methotrexate or other DMARDs for steroid-sparing effects 1
- Physical therapy and non-pharmacological approaches should be prioritized 1
Remember that the evidence supporting systemic corticosteroids for back pain is limited, while the risks of repeated courses are well-documented. Focus on addressing the underlying cause of back pain rather than repeated courses of steroids.