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

Prednisone Dosing for Back Pain

Systemic corticosteroids, including prednisone, are not recommended for treating back pain with or without sciatica, as they have not been shown to be more effective than placebo for pain relief. 1

Evidence Against Prednisone for Back Pain

• Multiple high-quality trials have consistently found no differences between systemic corticosteroids and placebo in pain or function for acute non-radicular low back pain 1
• Six trials consistently found no differences between systemic corticosteroids and placebo in pain or function for radicular low back pain 1, 2
• A randomized, double-blind, placebo-controlled trial showed no benefit from oral prednisone (50 mg daily for 5 days) in emergency department patients with musculoskeletal low back pain 3
• The Cochrane review indicates that systemic corticosteroids may only provide slight improvement in short-term pain and function for radicular back pain, but are probably ineffective for non-radicular back pain and spinal stenosis 2

Adverse Effects of Prednisone

• Oral prednisone increases the risk for adverse events, including insomnia, nervousness, and increased appetite, with a number needed to harm of 4 1
• Intramuscular corticosteroid injections are associated with an increased risk for adverse effects, with a relative risk of 6.4 1
• Systemic corticosteroids can cause hypothalamic-pituitary-adrenal axis depression lasting up to 3 weeks 4

Alternative Treatments for Back Pain

• NSAIDs and skeletal muscle relaxants have shown high-quality evidence of effectiveness for acute low back pain 1
• For chronic low back pain, NSAIDs, duloxetine, and tramadol have shown moderate evidence of effectiveness 1
• Non-pharmacologic options with proven benefits include:
  • Spinal manipulation for acute low back pain 1
  • Exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation for chronic or subacute low back pain 1

Special Circumstances

• For inflammatory arthritis affecting joints (not typical back pain), prednisone may be considered at 10-20 mg daily for 2-4 weeks if NSAIDs are ineffective 5
• For more severe inflammatory arthritis, prednisone 20 mg daily for 2-4 weeks may be used, with potential increase to 1 mg/kg/day if no response 5
• For specific cases of radicular pain, epidural steroid injections may be considered rather than oral prednisone 1, 6
• Epidural methylprednisolone acetate 40 mg appears to be as effective as 80 mg for chronic low back pain when epidural administration is indicated 6

Conclusion

Based on the most recent and highest quality evidence, systemic corticosteroids like prednisone should not be used for the treatment of back pain, whether radicular or non-radicular, as they provide minimal to no benefit while carrying significant risks of adverse effects 1, 2. NSAIDs, muscle relaxants, and non-pharmacologic approaches should be considered as first-line treatments instead 1.