What is the recommended dose of prednisone (corticosteroid) for treating back pain?

Prednisone for Back Pain: Evidence-Based Recommendations

Systemic corticosteroids such as prednisone are not recommended for treating non-radicular low back pain as they have not been shown to be more effective than placebo. 1

Evidence Summary

Non-Radicular Low Back Pain

• Multiple high-quality trials have consistently found no significant benefit of systemic corticosteroids over placebo for acute non-radicular low back pain 1
• Two trials (n=86 and 67) found no differences between systemic corticosteroids and placebo in pain or function for acute non-radicular back pain 1
• A randomized controlled trial specifically evaluating prednisone (50 mg daily for 5 days) for acute musculoskeletal low back pain found no benefit compared to placebo 2
• The American College of Physicians and American Pain Society explicitly state that "systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica" 1

Radicular Low Back Pain (Sciatica)

• For radicular low back pain, the evidence is slightly more nuanced:
  • Systemic corticosteroids may provide small, short-term benefits in pain reduction (0.56 points better on a 0-10 scale) 3
  • May slightly increase likelihood of functional improvement in the short term 3
  • However, these benefits are modest and may not be clinically significant

Spinal Stenosis

• For spinal stenosis, a trial (n=61) found no differences through 12 weeks between a 3-week course of prednisone and placebo in pain intensity or function 1
• A more recent study using low-dose oral prednisolone (10 mg daily for 1 week) for refractory lumbar spinal stenosis found no significant improvement in pain or disability, though walking distance showed some improvement 4

Adverse Effects

When used at higher doses (such as 60 mg/day), prednisone carries significant risks:

• Increased risk for any adverse event (49% vs. 24%) 1
• Insomnia (26% vs. 10%) 1
• Nervousness (18% vs. 8%) 1
• Increased appetite (22% vs. 10%) 1
• Other potential side effects include hyperglycemia, hypertension, mood changes, and osteoporosis with longer-term use 5

Alternative Treatment Approaches

For acute or chronic low back pain, guidelines recommend:

1. First-line options:

   • Non-pharmacologic therapies: staying active, heat, massage
   • NSAIDs or acetaminophen for pain relief

2. For chronic low back pain, evidence supports:

   • Exercise therapy
   • Acupuncture
   • Massage therapy
   • Yoga
   • Cognitive-behavioral therapy
   • Progressive relaxation 1

3. For acute low back pain with severe symptoms:

   • Spinal manipulation administered by providers with appropriate training 1
   • Short-term muscle relaxants if not responding to NSAIDs 1

Common Pitfalls to Avoid

1. Prescribing corticosteroids for non-specific back pain despite evidence showing lack of benefit
2. Using high-dose steroids for prolonged periods without clear indication, increasing risk of adverse effects
3. Failing to consider more effective non-pharmacologic approaches that have better evidence for back pain
4. Not distinguishing between radicular and non-radicular pain when considering treatment options

Conclusion

Based on the highest quality and most recent evidence, prednisone should not be routinely used for non-radicular low back pain. For radicular pain (sciatica), the benefits appear modest at best and must be weighed against potential adverse effects. Alternative treatments with better evidence of effectiveness should be prioritized for back pain management.