Oral Prednisone for Sciatica Flares
Oral prednisone provides modest short-term functional improvement for acute sciatica but does not improve pain significantly and should not be used as routine first-line therapy. 1
Evidence Against Systemic Corticosteroids
The highest quality evidence comes from clinical practice guidelines that explicitly recommend against systemic corticosteroids for sciatica:
- Systemic corticosteroids are not recommended for treatment of low back pain with or without sciatica, as they have not been shown to be more effective than placebo 1
- Multiple trials consistently found no differences between systemic corticosteroids and placebo in pain relief for radicular low back pain 1
- The American College of Physicians/American Pain Society guideline specifically states systemic corticosteroids should not be used for this indication 1
Limited Benefit from Recent High-Quality Trial
The most recent and highest quality study (2015 JAMA trial, n=269) showed:
- Modest functional improvement: 6.4-point greater improvement in Oswestry Disability Index at 3 weeks (95% CI, 1.9-10.9) 2
- No meaningful pain reduction: Only 0.3-point difference on 0-10 pain scale at 3 weeks (not statistically significant, p=0.34) 2
- No reduction in surgery rates at 52-week follow-up 2
- Significantly increased adverse events: 49.2% vs 23.9% in placebo group (p<0.001), including insomnia, nervousness, increased appetite, and fluid retention 1, 2
When Prednisone Might Be Considered
If you choose to use oral prednisone despite limited evidence, the following approach is supported:
- Dosing regimen: Tapering 15-day course (60 mg × 5 days, 40 mg × 5 days, 20 mg × 5 days; total 600 mg cumulative dose) 2
- Alternative shorter course: 30-35 mg daily for 3-5 days based on gout flare evidence extrapolation 1
- Timing: Most effective when given early in acute presentations (symptoms <6 months duration) 3, 4
- Patient selection: Consider only for patients with severe functional impairment who have contraindications to NSAIDs 1
Preferred Alternative Approaches
NSAIDs remain the evidence-based first-line treatment for sciatica flares, not corticosteroids 1
Epidural corticosteroid injections (not oral steroids) may provide short-term benefit for leg pain and sensory deficits, though functional benefit remains limited 5, 6
Clinical Pitfalls to Avoid
- Do not use oral prednisone expecting significant pain relief—the evidence shows minimal to no effect on pain intensity 1, 2
- Do not prescribe extended courses beyond 2-3 weeks, as no long-term benefit has been demonstrated 1
- Monitor diabetic patients closely for blood glucose elevation 7
- Be aware that nearly half of patients will experience steroid-related side effects 2
- The modest functional improvement (7.4 points on ODI at 1 year) must be weighed against the 49% adverse event rate 2