Prednisone Should Not Be Used for Low Back Pain
Systemic corticosteroids, including prednisone, are not recommended for acute inflammatory low back pain because they provide no meaningful clinical benefit over placebo and expose patients to unnecessary adverse effects. 1, 2
Evidence Against Corticosteroid Use
Lack of Efficacy
- The American College of Physicians guideline explicitly states that systemic corticosteroids show no difference in pain or function compared with placebo in patients with acute low back pain, whether radicular or non-radicular. 1, 2
- For radicular low back pain specifically, corticosteroids produce only a 0.56-point improvement on a 0-10 pain scale—well below the minimal clinically important difference. 2, 3
- Six randomized trials demonstrated no meaningful pain relief or functional improvement with systemic corticosteroids versus placebo. 2
- A high-quality emergency department trial of prednisone 50 mg daily for 5 days found no benefit in pain scores, return to work, or resuming normal activities. 4
Significant Adverse Effects
Prednisone causes substantial harm without benefit:
| Adverse Effect | Prednisone Group | Placebo Group |
|---|---|---|
| Any adverse event | 49% | 24% |
| Insomnia | 26% | 10% |
| Nervousness | 18% | 8% |
| Increased appetite | 22% | 10% |
- Patients receiving prednisone were more likely to seek additional medical treatment (40% vs 18%) compared to placebo, suggesting the medication may actually worsen outcomes. 4
What Actually Works: Evidence-Based Algorithm
First-Line Therapy: NSAIDs
- Initiate an NSAID at maximum tolerated dose as monotherapy for acute inflammatory back pain that does not improve with initial conservative measures. 1
- NSAIDs provide moderate-quality evidence for modest pain reduction and improvement in disability scores. 1
- No specific NSAID demonstrates superiority; prescribe any NSAID at the highest tolerated dose for the shortest duration needed. 5, 1
Second-Line: Add Muscle Relaxant
- When NSAID monotherapy is insufficient, add a skeletal muscle relaxant to the NSAID regimen for short-term pain relief in acute back pain. 1, 2
- This combination provides moderate-quality evidence for benefit in acute-on-chronic back pain with muscle spasm. 1
For Chronic Low Back Pain
- If NSAIDs and physical therapy are insufficient after several weeks, initiate duloxetine 30 mg daily for one week, then titrate to 60 mg daily if tolerated. 6
- Duloxetine has moderate-quality evidence for small but clinically meaningful improvements and is FDA-approved for chronic musculoskeletal pain. 6
Critical Clinical Distinctions
Non-Radicular vs Radicular Pain
- Corticosteroids are ineffective for both non-radicular and radicular low back pain—the distinction does not change the recommendation against their use. 1, 2
- Even for radicular pain with sciatica, systemic corticosteroids remain not recommended as standard therapy. 1
When Imaging Is NOT Needed
- Avoid routine imaging for acute low back pain without red flags (cauda equina syndrome, progressive neurologic deficits, infection, malignancy, or fracture). 2
- Most acute radicular pain improves within the first 4 weeks with conservative management alone. 2
Common Pitfalls to Avoid
- Do not prescribe a "burst-and-taper" prednisone regimen for routine acute back pain—this lacks supporting evidence and exposes patients to unnecessary corticosteroid risks including insomnia, nervousness, and increased appetite. 1, 2
- Do not use prednisone doses from other inflammatory conditions (such as the 10-20 mg daily for rheumatoid arthritis bridging therapy)—these dosing regimens do not apply to acute back pain and are not supported by evidence. 1
- Advise patients to remain active rather than prescribing bed rest, which is less effective for acute low back pain. 2, 7
- Provide patient education that most acute back pain improves over time with NSAIDs and activity modification, grounded in American College of Physicians guideline evidence. 1