Recommended Prednisone Dosing for Sciatica
For acute sciatica, a short course of oral prednisone at 60 mg daily for 5 days, followed by 40 mg daily for 5 days, then 20 mg daily for 5 days (total 15-day course with cumulative dose of 600 mg) is recommended. 1
Evidence-Based Dosing Regimen
The most recent high-quality evidence from a randomized clinical trial supports using a tapering 15-day course of oral prednisone for acute sciatica due to herniated lumbar disk:
- Days 1-5: 60 mg daily
- Days 6-10: 40 mg daily
- Days 11-15: 20 mg daily
This regimen demonstrated modest improvements in function compared to placebo, with benefits persisting at 52 weeks 1. The study showed:
- Greater improvement in disability scores at 3 weeks and 52 weeks
- Improved physical functioning at 3 weeks
- Improved mental component scores at 52 weeks
Clinical Considerations
Indications and Timing
- Most effective when initiated within the first 3-4 weeks of symptom onset
- Less effective when symptoms have persisted beyond 6 weeks 2
- Should be used as part of a comprehensive treatment approach that may include other non-pharmacologic therapies
Monitoring and Side Effects
- Common adverse events occur in approximately 49% of patients (vs. 24% with placebo) 1
- Monitor for:
- Blood pressure elevation
- Glucose levels (particularly in diabetic patients)
- Mood changes
- Sleep disturbances
- Signs of infection
Contraindications
- Active untreated infections
- Patients already receiving exogenous steroids
- Endocrine disorders where steroid administration may interfere with glucose-insulin regulation
Alternative Approaches
For patients who cannot tolerate oral steroids or have contraindications:
- Non-steroidal anti-inflammatory drugs (NSAIDs) can be considered as first-line therapy
- Physical therapy and exercise regimens may be beneficial for subacute and chronic sciatica
- For severe cases not responding to oral therapy, epidural steroid injections may be considered, though evidence suggests only short-term benefits 3
Important Caveats
- While the American College of Physicians and American Pain Society do not specifically recommend systemic corticosteroids for low back pain without sciatica 4, the evidence supports their use specifically for radicular pain (sciatica)
- The benefits of oral steroids must be weighed against potential adverse effects
- Never stop prednisone abruptly due to risk of adrenal insufficiency
- Consider calcium (1,000-1,200 mg/day) and vitamin D (600-800 IU/day) supplementation during treatment to mitigate bone health risks 4
This regimen represents the most evidence-based approach based on the most recent high-quality randomized controlled trial specifically designed to evaluate oral steroids for acute sciatica.