What is the recommended steroid regimen for gout (gouty arthritis) resistant to other therapies?

Steroid Regimen for Gout Resistant to Other Therapies

For gout resistant to other therapies, oral prednisone at 0.5 mg/kg per day for 5-10 days at full dose then stop, or alternatively for 2-5 days at full dose followed by tapering for 7-10 days, is the recommended steroid regimen. 1

Oral Steroid Options

When NSAIDs and colchicine are contraindicated, ineffective, or not tolerated, corticosteroids become the treatment of choice for acute gout. The following regimens are recommended:

First-line oral steroid regimen:

• Prednisone/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

Alternative oral option:

• Methylprednisolone dose pack: Following standard tapering schedule 1
  • This is considered an appropriate option according to provider and patient preference 1

Injectable Steroid Options

For patients unable to take oral medications or when rapid relief is needed:

Intra-articular injection:

• Recommended for involvement of 1-2 joints 1
• Dosing varies depending on joint size 1
• Can be used alone or in combination with oral therapy 1

Intramuscular injection:

• Triamcinolone acetonide: 60 mg single dose, followed by oral prednisone as above 1
• Note: There is no consensus on using intramuscular triamcinolone acetonide as monotherapy 1

Combination Therapy for Severe Cases

For severe acute gout attacks (≥7/10 pain) or polyarticular involvement:

• Initial combination therapy is appropriate 1
• Options include:
  • Oral corticosteroids and colchicine
  • Intra-articular steroids with other modalities 1

Treatment Duration and Monitoring

• Continue treatment until the gouty attack has completely resolved 1
• Monitor for inadequate response (defined as <20% improvement in pain within 24 hours or <50% improvement after ≥24 hours) 1
• If inadequate response occurs, consider alternative diagnoses or adding a second agent 1

Special Considerations

NPO (nil per os) patients:

• Intra-articular injection for 1-2 affected joints 1
• Intramuscular triamcinolone acetonide followed by oral steroids when possible 1

Potential adverse effects to monitor:

• Short-term: Dysphoria, mood disorders, elevated blood glucose 1
• Long-term (if prolonged use): Immune suppression, fluid retention 1

Contraindications:

• Systemic fungal infections 1
• Other known contraindications to steroid therapy

Prophylaxis During Urate-Lowering Therapy

If initiating urate-lowering therapy after the acute attack resolves:

• Low-dose prednisone/prednisolone (<10 mg/day) can be used as prophylaxis if colchicine and NSAIDs are not tolerated, contraindicated, or ineffective 1
• Continue prophylaxis for at least 6 months, or 3-6 months after achieving target serum urate (depending on presence of tophi) 1

Corticosteroids should be considered as first-line therapy for acute gout in patients without contraindications because they are generally safer and a low-cost treatment option compared to other alternatives 1.