What is the dose of prednisolone (corticosteroid) for an acute gouty attack?

Prednisolone Dosing for Acute Gouty Attack

For an acute gouty attack, prednisolone should be administered at a dose of 0.5 mg/kg per day for 5-10 days at full dose then stopped, or alternatively for 2-5 days at full dose followed by tapering for 7-10 days. 1

Initial Treatment Options for Acute Gout

The American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) guidelines provide clear recommendations for treating acute gout attacks:

Oral Corticosteroid Regimen:

• Prednisolone 0.5 mg/kg per day 1
• Duration options:
  • 5-10 days at full dose then stop, OR
  • 2-5 days at full dose followed by tapering for 7-10 days 1

The 2016 EULAR guidelines similarly recommend "oral corticosteroid (30-35 mg/day of equivalent prednisolone for 3-5 days)" as one of the first-line options for acute gout flares 1.

Alternative Corticosteroid Administration Routes:

• Intramuscular: Triamcinolone acetonide 60 mg, followed by oral prednisolone as above 1
• Intra-articular: Dose varies depending on joint size (can be used with or without oral therapy) 1

Treatment Algorithm

1. Start treatment as early as possible after flare onset 1
2. Choose prednisolone when:
   • NSAIDs are contraindicated (renal impairment, GI risks)
   • Colchicine is contraindicated or not tolerated
   • Patient has multiple affected joints or severe pain
3. Administer at 0.5 mg/kg per day
4. Continue for 5-10 days or use a 2-5 day course followed by 7-10 day taper

Clinical Evidence and Comparative Efficacy

Recent research supports the efficacy of prednisolone for acute gout. A multicenter, double-blind randomized trial found that oral prednisolone had similar analgesic effectiveness to indomethacin (an NSAID) for acute gout, with fewer adverse events in the emergency department phase 2.

Important Considerations and Pitfalls

• Do not interrupt ongoing urate-lowering therapy during an acute gout attack 1
• Combination therapy may be appropriate for severe attacks, particularly with involvement of multiple large joints. Acceptable combinations include oral corticosteroids with colchicine or intra-articular steroids with other modalities 1
• Avoid combining systemic corticosteroids with NSAIDs due to potential synergistic gastrointestinal toxicity 1
• For patients unable to take oral medications, intra-articular injection of corticosteroids is recommended for involvement of 1-2 joints 1

Alternative First-Line Options

If prednisolone is not appropriate, other first-line options include:

• Colchicine: 1 mg loading dose followed 1 hour later by 0.5 mg on day 1 (if started within 12 hours of flare onset) 1
• NSAIDs: At full FDA/EMA-approved doses for acute pain/gout 1

The choice between these options should be based on contraindications, previous treatment experience, time since flare onset, and the number and type of joints involved 1.