Oral Steroids Should NOT Be Used for Acute Lower Back Pain
Oral corticosteroids are not recommended for acute lower back pain—they provide no clinically meaningful benefit over placebo and should be avoided regardless of whether radicular symptoms are present. 1, 2
Evidence Against Oral Steroid Use
The American College of Physicians clinical practice guideline explicitly states that systemic corticosteroids should not be used for low back pain based on consistent evidence showing lack of efficacy. 1, 2 This recommendation applies to:
Acute non-radicular low back pain: Low-quality evidence showed no difference in pain or function between a 5-day course of oral prednisolone compared with placebo. 1
Acute radicular low back pain (sciatica): Moderate-certainty evidence from multiple high-quality trials consistently demonstrated that oral corticosteroids provide at most a clinically insignificant 0.56-point improvement on a 0-10 pain scale at short-term follow-up—far below the threshold for meaningful clinical benefit. 3
Any duration of symptoms: Six trials consistently found no meaningful differences between systemic corticosteroids and placebo for radicular pain relief. 4
Specific Trial Data on Oral Dosing
When oral prednisone has been studied, the regimens tested include:
50 mg prednisone daily for 5 days showed no benefit for pain, functional status, return to work, or days lost from work in emergency department patients with acute musculoskeletal low back pain. 5
Patients receiving prednisone actually sought additional medical treatment more frequently than placebo (40% vs 18%). 5
5-day course of oral prednisolone (dose not specified in guideline summary) showed no difference versus placebo in acute low back pain trials. 1
Adverse Effects to Consider
While short courses don't cause serious harms, oral prednisone increases the risk of adverse events with a number needed to harm of only 4, including: 4
- Insomnia
- Nervousness
- Increased appetite
- Hyperglycemia
- Facial flushing
- Gastrointestinal effects 2
What to Use Instead
First-line treatment should be NSAIDs, not corticosteroids. 2
NSAIDs provide small but statistically significant improvements in pain intensity (7.3-point reduction on 0-100 VAS scale) and disability (2-point improvement on 0-24 RMDQ scale) for acute low back pain. 6
For radicular pain specifically, combine NSAIDs with gabapentin to target both inflammatory and neuropathic components. 2, 7
Skeletal muscle relaxants (cyclobenzaprine 5-10 mg three times daily for maximum 2-3 weeks) can be added for acute exacerbations. 7, 4
Critical Clinical Pitfall
Despite the anti-inflammatory properties of corticosteroids that theoretically should help with nerve root inflammation in sciatica, clinical trials consistently demonstrate they do not provide meaningful pain relief. 2 This disconnect between theoretical mechanism and clinical reality is a common prescribing error to avoid.