How would you dose prednisone (corticosteroid) to help with radicular back pain?

Prednisone Dosing for Radicular Back Pain

Prednisone is not recommended for radicular back pain as systemic corticosteroids show no significant improvement in pain compared to placebo, despite potentially small improvements in function. 1

Evidence on Systemic Corticosteroids for Radicular Pain

The evidence regarding prednisone for radicular back pain shows:

• Moderate-quality evidence indicates systemic corticosteroids provide no significant difference in pain relief compared to placebo for radicular low back pain 1
• The largest high-quality trial (n=269) found that while prednisone did not improve pain significantly, it showed a small improvement in function (difference in Oswestry Disability Index at 52 weeks: 7.4 points, 95% CI 2.2-12.5) 2
• Systemic corticosteroids increase risk of adverse events (49% vs 24% with placebo), including insomnia (26% vs 10%), nervousness (18% vs 8%), and increased appetite (22% vs 10%) 1, 2

If Prednisone Is Still Being Considered

If despite the evidence, a trial of prednisone is being considered for severe radicular pain that has failed other treatments:

1. Dosing regimen from highest quality evidence:

   • Initial dose: 60 mg daily for 5 days
   • Then: 40 mg daily for 5 days
   • Then: 20 mg daily for 5 days
   • Total course: 15 days (total cumulative dose = 600 mg) 2

2. Administration considerations:

   • Take in the morning before 9 am to minimize adrenal suppression 3
   • Take with food or milk to reduce gastric irritation 3
   • Consider antacids between meals to help prevent peptic ulcers 3

Important Caveats and Monitoring

• Monitor for common adverse effects: insomnia, nervousness, increased appetite, mood changes, and hyperglycemia 1, 2
• Lower doses (40 mg) may be equally effective with potentially fewer adverse effects compared to higher doses (80 mg) 4
• Do not stop abruptly; follow the tapering schedule as prescribed 3
• Systemic corticosteroids should not be used for non-radicular low back pain 1

Alternative Approaches with Better Evidence

Instead of systemic corticosteroids, consider:

• For radicular pain with clear imaging correlation, epidural steroid injections have stronger evidence of effectiveness 5
• Non-steroidal anti-inflammatory drugs (NSAIDs) have better evidence for pain relief in both radicular and non-radicular back pain 1
• Duloxetine has moderate-quality evidence for chronic low back pain 1
• Physical therapy and appropriate medication management should be part of a comprehensive treatment approach 5

Conclusion

While the highest quality evidence (JAMA 2015 trial) showed a modest functional improvement with prednisone for radicular pain, the lack of significant pain improvement and increased risk of adverse effects makes systemic corticosteroids a poor choice for most patients with radicular back pain. Alternative approaches with better evidence should be prioritized.