Corticosteroids in the Treatment of Acute Low Back Pain

Written by Gerard Malanga, MD [1]

In This Article
Side Effects [2]

If you've been prescribed corticosteroids for acute low back pain, read on in this article about the effectiveness
of this treatment.

Oral steroids have been found effective in the treatment of inflammatory reactions associated with allergic
states, rheumatic and autoimmune diseases, and respiratory disorders. Corticosteroids interact with receptor
proteins in target tissues to regulate gene expression and ultimately protein synthesis by the target tissue. As
these interactions and regulatory processes occur slowly, most of the effects of corticosteroids are not immediate
and become apparent hours following their introduction. Recent investigations have suggested an additional and
more immediate component to corticosteroid action mediated by an interaction with membrane-bound protein
receptors.

[3]Over the past two decades, the biochemical contributions to sciatica and low back pain
have been the focus of much attention. In the late 1970's the nuclear material of the vertebral disc was found to
be antigenic and capable of producing an in vitro autoimmune reaction. It was hypothesized that a chemical
radiculitis might explain radicular pain in the absence of a more mechanical stressor.

Phospholipase A2 (PLA2), a potent inflammatory mediator, has demonstrated to be released by discs following
injury. The anti-inflammatory and immunosuppressive effects of glucocorticoids are largely secondary to their
inhibition of the immune responses of lymphocytes, macrophages, and fibroblasts. Whereas NSAIDs principally
inhibit prostaglandin synthesis, corticosteroids interfere earlier in the inflammatory cascade by inhibiting PLA2
actions and thereby curtailing both the leukotriene and prostaglandin mediated inflammatory response.

Studies: Corticosteroids and Acute Low Back Pain

Studies designed to investigate the use of oral steroids in the setting of acute low back pain are limited. In 1986,
Haimovic and Beresford compared oral dexamethasone (Decadron) with placebo in the treatment of 33
patients with lumbosacral radicular pain. Subjects receiving dexamethasone were given a tapering dose, from
64- to 8-mg over seven days. Early improvements (within seven days) were not significantly different between
the two groups, occurring in seven of 21 patients in the dexamethasone group and four of 12 in the placebo
group.

In those subjects initially found to have radicular type pain on straight leg-raising, however, eight of 19 treated
with dexamethasone, compared with only one of six in the placebo group, had diminished pain on straight leg
raising repeated within seven days. The limitations of this study include a small subject number, the use of
additional analgesics, which may have obscured group differences, the clinical uncertainty of a radicular process
in a significant number of subjects, and the loss of several patients to follow up after one year.

Other Articles in This Acute Low Back Pain Treatments Series

1. Medications and Treatment of Acute Low Back Pain: Overview [4]

2. Acetaminophen [5]

3. Non-steroidal Anti-inflammatories (NSAIDs) [6]

4. Muscle Relaxants [7]

5. Opioids [8]
 6. Corticosteroids in the Treatment of Low Back Pain

7. Colchichine [9]

8. Anti-depressant Medications [10]

9. Conclusion: Acute Low Back Pain and Medication [11]

Side Effects of Corticosteroid Treatment

In the setting of acute low back pain with radiculopathy, oral corticosteroids are typically prescribed in a
quick tapering fashion over one week. Multiple adverse effects have been associated with prolonged steroid use,
including suppression of the hypothalamic-pituitary-adrenal axis, immunosuppression, psuedotumor cerebri and
psychoses, cataracts and increased intraocular pressure, osteoporosis, aseptic necrosis, gastric ulcers, fluid and
electrolyte disturbances and hypertension, and impaired wound healing.

The severity of these complications correlates with the dosage, duration of use, and the potency of the steroid
prescribed. While the incidence of steroid-induced myopathy does not appear to be directly related to the dosage
of steroid prescribed nor the duration of use, it appears to be more prevalent with the use of steroids containing a
9-alpha fluorine configuration, such as triamcinolone (Aristocort). The relationship between hypertensive side
effects and the duration of therapy is also not very clear; steroids should be prescribed with greater caution in
the elderly, in those individuals with known hypertension, and when compounds with greater mineralocorticoid
properties are prescribed. As hyperglycemia is a well-known complication of corticosteroid use, oral steroids
should be prescribed with caution in the diabetic population.

As potent anti-inflammatory agents, oral steroids represent a theoretically useful agent in the treatment of
patients with radiculopathy due to local inflammation secondary to disc injury or herniation. While many
adverse effects are associated with oral steroid use, these are more frequently encountered in the setting of
prolonged administration. The effectiveness of oral steroids in the acute low back pain population remains
unproven; further research in this area is needed.

Footnotes:

Reference:
Malanga GA, et al. Pharmacologic Treatment of Low Back Pain. In Physical Medicine and Rehabilitation State
of the Art Reviews, Philadelphia, Hanley and Belfus Vol.13, No.3, October, 1999

Methylprednisolone Acetate Injection

Uses
Methylprednisolone is used to treat pain and swelling that occurs with arthritis and other joint
disorders. This medication may also be used to treat various conditions such as blood disorders,
severe allergic reactions, certain cancers, eye conditions,skin/intestinal/kidney/lung diseases,
and immune system disorders. It decreases your immune system's response to these conditions and
reduces symptoms such as swelling, pain, and allergic-type reactions. Talk to your doctor about the
risks and benefits of methylprednisolone, especially if it is to be injected near your spine (epidural).
Rare but serious side effects may occur with epidural use. Methylprednisolone is a corticosteroid
hormone.
Methylprednisolone may also be used with other medications in hormone disorders.

How to use methylprednisolone acetate injection

Shake this medication well before using. This medication is usually injected into a joint as directed by
your doctor. Methylprednisolone may also be injected into a muscle or into abnormal skin tissue.
Follow your doctor's directions carefully. The dosage is based on your medical condition and response
to treatment. Do not increase your dose or use this drug more often than prescribed without
consulting your doctor. Your condition will not improve any faster, and your risk of side effects will
increase.

If you are using this medication at home, learn all preparation and usage instructions from your health
care professional. This medication should appear milky white. Before using, check this product
visually for particles or discoloration. If either is present, do not use the liquid. Learn how to store and
discard medical supplies safely.
If this medication is injected into a joint, be careful how much pressure you put on that joint, even if it
is feeling better. Ask your doctor how much you can move/use the joint while it is healing.

Do not stop using this medication without consulting your doctor. Some conditions may worsen or you
may experience withdrawal symptoms (such as weakness, weight loss, nausea, muscle
pain, headache, tiredness, dizziness) when this drug is suddenly stopped. To prevent these
withdrawal symptoms when stopping methylprednisolone, your doctor may reduce your dose
gradually. Consult your doctor or pharmacist for more details and report any withdrawal reactions right
away. See also Precautions section.
Tell your doctor if your condition does not improve or if it worsens.

Conditions

What conditions does methylprednisolone acetate injection treat?

methylprednisolone acetate injection is used to treat the following:

Infection caused by the Trichinae Parasite, Sarcoidosis, Disease with Enlarged Lymph Tissue, Spleen
and Liver, Chronic Malignant T-Cell Lymphoma of the Skin, Non-Hodgkin's Lymphoma, Type of
Leukemia - Acute Lymphocytic Leukemia, Increased Calcium in the Blood from Cancer, Thyroid Gland
Inflammation, Condition caused by Excess Secretion of Male Hormones, Severely Decreased
Function of the Cortex of Adrenal Gland, Decreased Function of the Adrenal Gland, Inflammation of
the Joints due to Gout, Disease in which Body has Immune Response Against Itself, Destruction of
Red Blood Cells by Body's Own Antibodies, Constitutional Aplastic Anemia, A Hereditary Progressive
Anemia of Unknown Cause, Anemia From Too Few Young Red Blood Cells, Low Platelet Count and
Bleeding from Immune Response, Decreased Platelets due to a Disease State or a Drug, Acute
Exacerbation of Multiple Sclerosis, Fluid Accumulation in the Brain, Eye Disorder, Inflammation of the
Heart with Rheumatic Fever, Vocal Cord Swelling, Severe Prolonged Asthma Attack, Asthma,
Beryllium Poisoning, Inflammation of Lung from Inhaling Something Irritating, Infiltration of White
Blood Cells into the Lungs, Crohn's Disease, Ulcerated Colon, Inflammatory Bowel Disease,
Nephrotic Syndrome, Atopic Dermatitis, Contact Dermatitis, Chronic Inflammatory Skin Disease
Marked by Blisters, Blistering Skin Diseases, Erythema Multiforme, Skin Rash with Sloughing,
Psoriasis associated with Arthritis, Psoriasis, Reaction Following Transfusion with Hives, Systemic
Lupus Erythematosus, Inflammation of Skin and Muscles All Over the Body, Rheumatoid Arthritis,
Joint Inflammatory Disease in Children and Young Adults, Any Disease Following Trauma Involving
Joint Cartilage, Joint Capsule Membrane Inflammation of a Diseased Joint, Rheumatic Disease
causing Pain & Stiffness in Backbone, Inflammation of the Tendon, Inflammation of the Covering of
the Tendon, Inflammation of the Lining of a Joint, Inflammation of the Sac Surrounding the Joint -
Bursitis, Rash, Giant Hives, Allergic Reaction caused by a Drug, Body's Rejection of a Transplanted
Organ, Allergic Reaction causing Serum Sickness
methylprednisolone acetate injection may also be used to treat:

Severe Newborn Breathing Problem with Blue Discoloration, Abnormal Development of

Bronchopulmonary Tissue in Newborn

Side Effects
Nausea, vomiting, heartburn, headache, dizziness, trouble sleeping, appetite changes,
increased sweating, acne, or pain/redness/swelling at the injection site may occur. If any of these
effects persist or worsen, tell your doctor or pharmacist promptly.
Remember that your doctor has prescribed this medication because he or she has judged that the
benefit to you is greater than the risk of side effects. Many people using this medication do not have
serious side effects.

This medication may make your blood sugar level rise, which can cause or worsendiabetes. Tell your
doctor right away if you develop symptoms of high blood sugar, such as increased thirst and urination.
If you already have diabetes, be sure to check your blood sugars regularly. Your doctor may need to
adjust your diabetes medication, exercise program, or diet.
This medication may lower your ability to fight infections. This may make you more likely to get a
serious (rarely fatal) infection or make any infection you have worse. Tell your doctor right away if you
have any signs of infection (such as fever, chills, persistent sore throat, cough, white patches in the
mouth).

Tell your doctor right away if you have any serious side effects, including: unusual weight gain,
menstrual period changes, bone/joint pain, easy bruising/bleeding, mental/mood changes (such as
mood swings, depression, agitation), muscle weakness/pain, puffy face, slow wound healing, swelling
of the ankles/feet/hands, thinning skin, unusual hair/skin growth, vision problems, fast/slow/irregular
heartbeat.

This drug may rarely cause serious (rarely fatal) bleeding from the stomach or intestines. If you notice
any of the following unlikely but serious side effects, consult your doctor or pharmacist right away:
black/bloody stools, persistent stomach/abdominal pain, vomit that looks like coffee grounds.

Get medical help right away if you have any very serious side effects, including: seizures.

A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice
any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the
face/tongue/throat), severe dizziness, trouble breathing.

This is not a complete list of possible side effects. If you notice other effects not listed above, contact
your doctor or pharmacist.

Precautions
Before using methylprednisolone, tell your doctor or pharmacist if you are allergic to it; or to
prednisone; or if you have any other allergies. This product may contain inactive ingredients, which
can cause allergic reactions or other problems. Talk to your pharmacist for more details.

Before using this medication, tell your doctor or pharmacist your medical history, especially of:
bleeding problems, blood clots, brittle bones (osteoporosis), diabetes, eye diseases (such as
cataracts, glaucoma, herpes infection of the eye), heart problems (such as congestive heart failure,
recent heart attack), high blood pressure, current/ past infections (such as those caused by
tuberculosis, threadworm, herpes, fungus), kidney disease, liver disease, mental/mood conditions
(such as psychosis, anxiety, depression), stomach/intestinal problems (such as diverticulitis, ulcer,
ulcerative colitis), seizures.

Methylprednisolone may make you dizzy. Do not drive, use machinery, or do any activity that requires
alertness until you are sure you can perform such activities safely.

This medicine may cause stomach bleeding. Daily use of alcohol while using this medicine may
increase your risk for stomach bleeding.

Limit alcoholic beverages to decrease risk of dizziness and stomach bleeding. Consult your doctor or
pharmacist for more information.

Methylprednisolone can make you more likely to get infections or may worsen any current infections.
Therefore, wash your hands well to prevent the spread of infection. Avoid contact with people who
have infections that may spread to others (such as chickenpox, measles, flu). Consult your doctor if
you have been exposed to an infection or for more details.

This medication may cause vaccines to not work as well. Live vaccines may cause serious problems
(such as infection) if given while you are using this medication. Do not have immunizations,
vaccinations, or skin tests without the consent of your doctor. Avoid contact with people who have
recently received live vaccines (such as flu vaccine inhaled through the nose).

Before having surgery, tell your doctor or dentist about all the products you use (including prescription
drugs, nonprescription drugs, and herbal products).

Using corticosteroid medications for a long time can make it more difficult for your body to respond to
physical stress. Therefore, before having surgery or emergency treatment, or if you get a serious
illness/injury, tell your doctor or dentist that you are using this medication or have used this medication
within the past 12 months. Tell your doctor right away if you develop unusual/extreme tiredness or
weight loss. If you will be using this medication for a long time, carry a warning card or medical ID
bracelet that identifies your use of this medication. See also Medical Alert section.

Older adults may be more sensitive to the side effects of this drug, especially brittle bones
(osteoporosis). Talk to your doctor about ways to prevent osteoporosis. See also Notes section.

This medication may slow down a child's growth if used for a long time. Consult the doctor or
pharmacist for more details. See the doctor regularly so your child's height and growth can be
checked.

During pregnancy, this medication should be used only when clearly needed. It may rarely harm an
unborn baby. Discuss the risks and benefits with your doctor. Infants born to mothers who use this
medication for a long time during pregnancy may have hormone problems. Tell your doctor right away
if you notice symptoms such as persistent nausea/vomiting, severe diarrhea, or weakness in your
newborn.

This medication passes into breast milk but is unlikely to harm a nursing infant. Consult your doctor
before breast-feeding.

Interactions
Drug interactions may change how your medications work or increase your risk for serious side
effects. This document does not contain all possible drug interactions. Keep a list of all the products
you use (including prescription/nonprescription drugs and herbal products) and share it with your
doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your
doctor's approval.

Some products that may interact with this drug include: aldesleukin, mifepristone, other drugs that can
also cause bleeding/bruising (including antiplatelet drugs such as clopidogrel, "blood thinners" such
as warfarin/dabigatran, NSAIDs such as ibuprofen, celecoxib, aspirin, salicylates).

If your doctor has directed you to take low-dose aspirin for heart attack or stroke prevention (usually at
dosages of 81-325 milligrams a day), you should continue taking it unless your doctor instructs you
otherwise. Ask your doctor or pharmacist for more details.

Other medications can affect the removal of methylprednisolone from your body, which may affect
how methylprednisolone works. Examples include azole antifungals (such as ketoconazole),
boceprevir, cyclosporine, estrogens, HIV protease inhibitors (such as ritonavir), macrolide antibiotics
(such as erythromycin), rifamycins (such as rifampin), St. John's wort, some drugs used to treat
seizures (such as phenytoin, phenobarbital, carbamazepine), telaprevir, among others.

This medication may interfere with certain laboratory tests (including skin tests), possibly causing
false test results. Make sure laboratory personnel and all your doctors know you use this drug.

Overdose
If overdose is suspected, contact a poison control center or emergency room right away. US residents
can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial
poison control center.

Notes

Do not share this medication with others.

Laboratory and/or medical tests (such as blood sugar/mineral levels, blood pressure, bone density
tests, height/weight measurements, eye exams) should be performed periodically to monitor your
progress or check for side effects during long-term treatment. Consult your doctor for more details.

Lifestyle changes that help reduce the risk of bone loss (osteoporosis) during long-term treatment
include doing weight-bearing exercise, getting adequate calcium and vitamin D, stopping smoking,
and limiting alcohol. Consult your doctor for specific advice.

Missed Dose

For the best possible benefit, it is important to receive each scheduled dose of this medication as
directed. If you miss a dose, contact your doctor or pharmacist right away to establish a new dosing
schedule. Do not double the dose to catch up.

Storage

Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all
medications away from children and pets.

Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly
discard this product when it is expired or no longer needed. Consult your pharmacist or local waste
disposal company.