Is a prednisone (corticosteroid) taper effective for treating sciatica?

Prednisone Taper for Sciatica

Prednisone tapers are not recommended as a primary treatment for sciatica due to limited evidence of clinical benefit and potential for adverse effects. 1

Evidence Against Systemic Corticosteroids for Sciatica

• Multiple high-quality trials demonstrate no significant clinical benefit of systemic corticosteroids for radicular low back pain compared to placebo 1
• The American College of Physicians strongly recommends against systemic glucocorticoids for treatment of back pain conditions 1
• Three small higher-quality trials consistently found no clinically significant benefit of systemic corticosteroids compared with placebo when given parenterally or as a short oral taper for radicular pain 1

Limited Evidence of Modest Benefit

• In one randomized clinical trial, a 15-day tapering course of oral prednisone (60mg, 40mg, then 20mg for 5 days each) showed modest improvement in function (Oswestry Disability Index) compared to placebo, but no significant improvement in pain at 3 weeks 2
• Another small study showed slightly more rapid rates of improvement in pain, mental well-being, and disability scores with prednisone, but no significant effect on physical findings, medication use, or return to work rates 3

Risks of Oral Corticosteroids

• Prednisone increases risk for adverse events including:
  • Insomnia
  • Nervousness
  • Increased appetite
  • Transient hyperglycemia
  • Facial flushing 1
• In the 2015 randomized trial, adverse events at 3-week follow-up were significantly more common in the prednisone group (49.2%) than in the placebo group (23.9%) 2

Recommended Alternatives for Sciatica

1. First-line treatments:

   • Non-pharmacological approaches: maintaining physical activity, local heat application, and massage therapy 1
   • NSAIDs/COXIBs at maximum tolerated dosage 4, 1

2. Second-line options:

   • Gabapentin may be considered for neuropathic pain components of sciatica 5
   • Epidural steroid injections may provide short-term improvement in leg pain and sensory deficits, though they offer no significant functional benefit or reduction in surgery rates 6

3. Special considerations:

   • Short courses of oral prednisone with rapid tapering might be considered as a bridging option in limited circumstances while awaiting the effect of other agents 4
   • Local glucocorticoid injections may be more effective than systemic administration 4

When to Consider Surgery

• For patients with persistent symptoms despite conservative management
• For patients with spinal bone lesions with risk of vertebral collapse 4
• For patients presenting with significant accumulated skeletal damage 4

Bottom Line

Prednisone tapers should not be routinely used for sciatica. The evidence suggests minimal benefit with potential for adverse effects. Focus instead on NSAIDs, non-pharmacological approaches, and consider gabapentin or epidural injections for persistent symptoms.