How should I prescribe a short‑course oral prednisone for an adult with acute severe sciatica refractory to NSAIDs and physical therapy, assuming no contraindications such as uncontrolled diabetes, infection, peptic ulcer disease, severe osteoporosis, psychosis, or hypersensitivity?

Prednisone for Sciatica: Prescribing Guidance

Based on the highest-quality evidence, prescribe prednisone 60 mg daily for 5 days, then 40 mg daily for 5 days, then 20 mg daily for 5 days (total 15-day tapering course, cumulative dose 600 mg) for acute severe sciatica refractory to NSAIDs and physical therapy. 1

Evidence Supporting This Regimen

The most rigorous trial evaluating oral steroids for sciatica—a randomized, double-blind, placebo-controlled study of 269 patients—demonstrated that this specific 15-day tapering protocol produces:

• Modest functional improvement: 6.4-point greater improvement in Oswestry Disability Index at 3 weeks (P=0.006) and 7.4-point greater improvement at 52 weeks (P=0.005) compared to placebo 1
• No significant pain reduction: Only 0.3-point difference at 3 weeks (P=0.34) and 0.6-point difference at 52 weeks (P=0.15) on a 0-10 pain scale 1
• Quality of life benefit: 3.3-point greater improvement in SF-36 Physical Component Summary at 3 weeks (P=0.001) 1

Critical Prescribing Details

Dosing Schedule

• Days 1-5: Prednisone 60 mg once daily 1
• Days 6-10: Prednisone 40 mg once daily 1
• Days 11-15: Prednisone 20 mg once daily 1
• Total cumulative dose: 600 mg 1

Timing and Administration

• Administer in the morning prior to 9 AM to minimize HPA axis suppression 2
• Take with food or milk to reduce gastric irritation 2
• Consider prescribing a proton pump inhibitor for GI prophylaxis, particularly given the patient's prior NSAID use 3

Setting Realistic Patient Expectations

You must counsel the patient that prednisone provides only modest functional improvement and does NOT significantly reduce leg pain. 1 The primary benefit is improved disability scores and physical function, not pain relief. 1

The clinical course of sciatica is generally favorable regardless of treatment, with most patients improving over 6-8 weeks. 4 This natural history makes it difficult to attribute improvement solely to medication.

Adverse Effects to Monitor

The prednisone group experienced significantly higher rates of adverse events compared to placebo (49.2% vs 23.9%, P<0.001). 1 Common short-term effects include:

• Insomnia and mood changes 1
• Increased appetite and weight gain 1
• Hyperglycemia (monitor in patients with diabetes risk factors) 2
• Gastrointestinal symptoms 1

Important Clinical Caveats

When NOT to Use This Regimen

• Non-radicular back pain: Systemic corticosteroids show no benefit over placebo for acute non-radicular low back pain and should NOT be used 5
• Muscle spasm without radiculopathy: Corticosteroids are ineffective; use NSAIDs plus skeletal muscle relaxants instead 5

Alternative Evidence

One smaller trial (n=59) using prednisolone 50 mg daily for 5 days tapered over 10 days showed greater pain reduction in cervical radiculopathy (75.8% vs 30% improvement, P<0.001). 6 However, this studied cervical rather than lumbar radiculopathy and used a different dosing regimen. 6

Epidural Injections Are Not Superior

Epidural methylprednisolone injections offer no significant functional benefit over placebo at 3 months and do not reduce surgery rates (25.8% vs 24.8%, P=0.90). 7 The oral route is therefore preferred for its convenience and similar efficacy profile. 1

Contraindications to Verify Before Prescribing

As specified in your clinical scenario, ensure absence of:

• Uncontrolled diabetes (prednisone will worsen glycemic control) 2
• Active infection (immunosuppression risk) 2
• Peptic ulcer disease (increased GI bleeding risk) 2
• Severe osteoporosis (accelerated bone loss) 2
• Psychosis (corticosteroids can precipitate psychiatric symptoms) 2
• Hypersensitivity to prednisone 2

Follow-Up Strategy

• Reassess at 3 weeks to evaluate functional improvement using validated disability measures 1
• Do NOT abruptly discontinue after the 15-day course; the taper is built into the regimen 2
• If no improvement by 3 weeks, consider MRI if not already obtained and neurosurgical consultation for possible discectomy 1
• Surgery discussion: Discectomy is effective for short-term relief but shows no long-term advantage over conservative care, so shared decision-making is essential 4

Why NSAIDs Alone Are Insufficient in This Case

Your patient has already failed NSAIDs, which show only modest benefit for sciatica (mean difference -4.56 on 0-100 VAS, not statistically significant). 8 The evidence for NSAIDs in sciatica is very low quality with high heterogeneity. 8 Adding prednisone provides an additional mechanism targeting nerve root inflammation beyond what NSAIDs achieve. 1