Steroids for Pain Flare
By: Steven Richeimer, MD Chief, Division of Pain Medicine
Professor of Anesthesiology & Psychiatry
Director, Online Master Degree in Pain Medicine
University of Southern California
Are steroids useful in the treatment of complex regional pain syndrome?
Steroids are one of the oldest treatments for complex regional pain syndrome. They appear to be most effective in the very early stages of the condition, or during acute flares.
How much steroid should be taken, and for how long?
For new onset of symptoms of complex regional pain syndrome, I typically treat patients with either a 12 day or an 18 day course. Methylprednisolone is available in blister packs (commonly referred to as Medrol dosepacks). Each dosepack is a six day treatment course. We will use two dosepacks in an alternating fashion so that the patient will get 24 mg of methylprednisolone on day one and on day two, then 20 mg on day three and four, and continuing to reduce the dose by 4 mg every two days. For more severe symptoms, we may use prednisone, starting at 60 milligrams per day for three days, decreasing the dose every three days until the course of treatment is completed after 18 days. For acute flares of CRPS, I will. Typically the limit usage to a 6 day course of methylprednisolone (a single dose pack).
Are there risks of using steroids?
The use of steroids is associated with multiple side effects and potential complications that is why we are so careful to limit their use to short time periods. Complications include increase blood sugar, increase blood pressure, osteoporosis, thinning of head hair, increased facial or bodily hair, increased weight especially in the face and abdomen, muscle atrophy, easy bruising, thinning of the skin, and effects on mood and cognition. Even this extensive list is not a comprehensive list of all tile potential problems with the use of steroids.
Given these risks, should a patient with complex regional pain syndrome still consider the use of steroids as a possible treatment?
In the vast majority of situations steroids are not appropriate for chronic treatment of CRPS. Nevertheless, they are potentially very useful for brief treatment of the acute symptoms that might be seen with new onset or flares. For brief treatment courses, the side effects are usually minimal to mild. For patients who have repetitive flares, I will limit the use of a six-day course of steroids to two to three times per year.
Why do steroids work?
This is far from clear, but steroids have several properties that seem to be helpful. Steroids reduce the abnormal firing of damaged or irritated nerves. In addition, steroids are powerful anti-inflammatory agents and also suppressors of immune function. At least one component of CRPS appears to be an autoimmune disorder: The anti-inflammatory and immunosuppressive properties of steroids appears to be very helpful for acute neuropathic pain conditions, including CRPS.