Is a non-tapered dose of oral steroids, such as prednisone (corticosteroid), effective for treating lower back pain?

Non-Tapered Oral Steroids for Lower Back Pain

Oral corticosteroids are not recommended for treating lower back pain as they show no clinically significant benefit compared to placebo for both non-radicular and radicular low back pain. 1

Evidence Against Systemic Corticosteroids for Low Back Pain

Non-Radicular Low Back Pain

• Multiple high-quality trials consistently demonstrate no benefit of systemic corticosteroids for acute non-radicular low back pain 2
• Two trials found no differences between a single intramuscular injection or a 5-day course of systemic corticosteroids and placebo in pain or function 2
• A randomized controlled trial found no difference in pain relief between a single intramuscular methylprednisolone injection and placebo through 1 month of follow-up 2
• A 2014 randomized controlled trial specifically examining prednisone (50mg daily for 5 days) for acute low back pain found no benefit compared to placebo for pain relief or functional outcomes 3

Radicular Low Back Pain

• For radicular low back pain, evidence shows minimal to no benefit, with three small higher-quality trials consistently finding systemic corticosteroids provided no clinically significant benefit compared with placebo when given parenterally or as a short oral taper 2
• A 2022 Cochrane review found that while systemic corticosteroids may provide a statistically significant improvement in short-term pain for radicular low back pain (mean difference 0.56 points better on a 0-10 scale), this difference is small and likely not clinically meaningful 4
• For spinal stenosis, one trial found no differences through 12 weeks between a 3-week course of prednisone and placebo in pain intensity or function 2

Adverse Effects of Corticosteroids

Even short-term use of oral corticosteroids carries risks:

• Oral prednisone increases risk for adverse events, insomnia, nervousness, and increased appetite 2, 1
• Other documented adverse effects include transient hyperglycemia and facial flushing 2, 1
• The FDA label for prednisone notes multiple potential adverse effects even with short-term use 5
• Patients in the prednisone group were more likely to seek additional medical treatment (40% vs 18%) in one study 3

Recommended Alternatives for Low Back Pain

The American College of Physicians recommends:

1. First-line non-pharmacological approaches:

   • Maintaining physical activity
   • Applying local heat
   • Massage therapy 2, 1

2. First-line medications:

   • Acetaminophen - safer side effect profile but modest effect
   • NSAIDs - moderate-quality evidence shows they are slightly more effective than placebo for short-term pain reduction and disability improvement 2, 6
   • Skeletal muscle relaxants - for acute low back pain with muscle spasm 2

3. For neuropathic components (if radicular symptoms present):

   • Consider gabapentin or pregabalin rather than corticosteroids 1

Clinical Bottom Line

When treating lower back pain, clinicians should avoid prescribing oral corticosteroids as they do not provide clinically meaningful benefits and expose patients to unnecessary risks. Instead, focus on evidence-based treatments including NSAIDs, acetaminophen, muscle relaxants, and non-pharmacological approaches such as physical activity and heat therapy. This approach aligns with the American College of Physicians guidelines and prioritizes treatments that improve outcomes while minimizing harm 2, 1.