What is the role of oral steroids, such as prednisone, in the treatment of sciatica?

Oral Steroids for Sciatica: Limited Benefit with Unfavorable Risk Profile

Systemic oral steroids should generally be avoided for sciatica due to an unfavorable risk-benefit profile, as high-quality trials show no clinically significant pain reduction compared to placebo. 1

Evidence Assessment

The most recent and highest quality evidence regarding oral steroids for sciatica comes from a systematic review in the Annals of Internal Medicine (2017) and a randomized clinical trial published in JAMA (2015):

• For radicular low back pain, multiple trials consistently found no significant differences between systemic corticosteroids and placebo in pain reduction 2
• The largest good-quality trial (n=269) showed that oral prednisone provided only modest functional improvement (difference in ODI at 52 weeks, 7.4 points) but no significant effect on leg pain 3
• Oral prednisone significantly increased risk for adverse events (49% vs. 24% with placebo), including insomnia (26% vs. 10%), nervousness (18% vs. 8%), and increased appetite (22% vs. 10%) 2, 3

Treatment Algorithm for Sciatica

First-Line Approaches (Recommended)

1. Non-pharmacological interventions:

   • Maintain physical activity
   • Apply local heat
   • Consider physiotherapy
   • Patient education on natural history of condition

2. First-line medications:

   • NSAIDs/COXIBs at maximum tolerated dosage
   • Evaluate response at 2-4 weeks
   • If insufficient response, consider NSAID/COXIB rotation 1

Second-Line Approaches (For Persistent Symptoms)

1. Analgesics:

   • Consider for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated
   • Options include paracetamol and opioids (short-term use) 2

2. Targeted interventions:

   • Local corticosteroid injections directed to specific sites of inflammation may be more effective than systemic administration 1
   • Epidural steroid injections may provide short-term improvement in leg pain but offer no significant functional benefit or reduction in surgery rates 1

Role of Oral Steroids (Limited)

Oral steroids might only be considered in very specific circumstances:

• As a short-term bridging option (maximum 15 days)
• When awaiting the effect of other agents
• When other treatment options have failed
• With careful monitoring for adverse effects 2, 1

Important Caveats and Pitfalls

1. Adverse effects risk: Short courses of oral prednisone significantly increase risk of adverse events including insomnia, nervousness, increased appetite, and potential for hyperglycemia 2, 3

2. Limited efficacy: The modest functional improvement seen with oral steroids must be weighed against the lack of significant pain reduction 3

3. Duration of therapy: If used, oral steroids should be limited to short courses (typically 7-15 days) with tapering doses to minimize adverse effects 1

4. Alternative approaches: Consider epidural steroid injections for targeted delivery with potentially fewer systemic effects when appropriate 1

5. Long-term use: Avoid long-term use of glucocorticoids for sciatica as this increases risk of serious adverse effects without evidence of sustained benefit 2

By following this evidence-based approach, clinicians can optimize outcomes for patients with sciatica while minimizing unnecessary exposure to medications with unfavorable risk-benefit profiles.