In an adult with acute inflammatory back pain unresponsive to NSAIDs and physical therapy, what prednisone dose and taper (or burst) regimen is recommended?

Prednisone for Acute Back Pain: Not Recommended

Do not use prednisone for acute non-radicular back pain—systemic corticosteroids provide no benefit over placebo and are explicitly not recommended by the American College of Physicians. 1, 2

Evidence Against Corticosteroid Use

The highest quality guideline evidence demonstrates that systemic corticosteroids are ineffective for acute low back pain:

• The American College of Physicians found no difference in pain or function between systemic corticosteroids and placebo in patients with acute low back pain, based on their comprehensive 2017 systematic review 1
• For non-radicular back pain specifically, corticosteroids show no benefit and should not be used 2
• This recommendation applies regardless of whether muscle spasm is present 2

What Actually Works: First-Line Treatment Algorithm

Start with NSAIDs as monotherapy for acute inflammatory back pain unresponsive to initial conservative measures 1, 3:

• Use maximum tolerated doses of NSAIDs (no specific NSAID is superior to another) 1, 3
• NSAIDs provide moderate-quality evidence for small but statistically significant pain reduction (mean difference -7.29 points on 0-100 VAS scale) 3
• NSAIDs also improve disability scores (mean difference -2.02 points on 0-24 RMDQ scale) 3

If NSAIDs alone are insufficient, add a skeletal muscle relaxant to the NSAID regimen 1, 2:

• The combination of NSAIDs plus muscle relaxants provides moderate-quality evidence for short-term pain relief in acute back pain 1, 2
• Be aware that adding muscle relaxants increases CNS adverse events (sedation, dizziness) but may reduce GI adverse events 2

Critical Distinction: When Corticosteroids Might Be Considered

The evidence against corticosteroids applies specifically to non-radicular back pain. The distinction matters:

• Non-radicular pain (localized back pain, muscle spasm): No role for corticosteroids 1, 2
• Radicular pain with sciatica: Limited evidence suggests possible modest efficacy for opioids, but corticosteroids still not recommended as standard treatment 1

If You Must Use Corticosteroids as Bridging Therapy

While not recommended for back pain specifically, if corticosteroids are used in other inflammatory conditions, expert consensus suggests 1:

• Short courses only as bridging therapy while awaiting effect of other agents 1
• Avoid long-term use of glucocorticoids 1
• Typical bridging doses in inflammatory arthritis range from prednisone 10-20 mg daily for grade 2 symptoms 1
• For more severe inflammatory conditions, doses of 0.5-1 mg/kg may be used 1

However, these dosing recommendations do not apply to acute back pain, where corticosteroids have no proven benefit 1, 2.

Common Pitfalls to Avoid

• Do not prescribe prednisone "burst and taper" or any other regimen for routine acute back pain—this practice lacks evidence and exposes patients to unnecessary corticosteroid risks 1, 2
• Do not confuse acute gout treatment (where prednisone is effective) 4 with acute back pain (where it is not) 1, 2
• Avoid bed rest—it should be minimized if possible 5
• Patient education is essential: Explain that most acute back pain improves with time, NSAIDs, and activity modification 1, 5