What is the recommended dose of prednisone (corticosteroid) for treating a gout flare?

Recommended Prednisone Dosing for Acute Gout Flare

For acute gout flares, prednisone should be administered at a dose of 0.5 mg/kg per day for 5-10 days at full dose, then stopped; or alternatively, given for 2-5 days at full dose followed by a taper over 7-10 days. 1

Oral Corticosteroid Regimens for Gout Flare

The American College of Rheumatology (ACR) guidelines provide specific dosing recommendations for oral prednisone in managing acute gout flares:

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

Alternatively, a methylprednisolone dose pack can be used, followed by appropriate follow-up treatment 1.

European League Against Rheumatism (EULAR) Recommendations

The 2017 EULAR guidelines recommend:

• Oral prednisolone 30-35 mg/day for 3-5 days 1
• This dosing has been shown to have analgesic effectiveness equivalent to NSAIDs in randomized trials 1

Clinical Decision Making Algorithm

1. Assess patient for contraindications to corticosteroids:

   • Systemic fungal infections
   • Uncontrolled diabetes
   • Active peptic ulcer disease

2. Select appropriate dose based on patient weight:

   • Calculate 0.5 mg/kg/day of prednisone
   • For a 70 kg patient, this equals approximately 35 mg daily

3. Choose duration strategy:

   • Option A: Full dose for 5-10 days then stop
   • Option B: Full dose for 2-5 days then taper over 7-10 days
   • Option C: Methylprednisolone dose pack (pre-packaged taper)

Evidence Quality and Comparative Effectiveness

High-quality evidence shows that corticosteroids, NSAIDs, and colchicine are all effective treatments for acute gout pain 1. A double-blind randomized equivalence trial demonstrated that prednisolone (35 mg/day for 5 days) was equivalent to naproxen (500 mg twice daily for 5 days) for treating acute gout 2.

A systematic review found no difference in pain reduction between corticosteroids and NSAIDs, but corticosteroids had a more favorable safety profile with lower risks of indigestion, nausea, and vomiting 3.

Important Clinical Considerations

• Early treatment: Initiate treatment as early as possible after symptom onset for best effectiveness 1
• Renal impairment: Prednisone may be preferred over colchicine or NSAIDs in patients with renal dysfunction 1
• Combination therapy: For severe acute gout attacks, particularly with polyarticular involvement, combination therapy may be appropriate (e.g., corticosteroids plus colchicine) 1
• Prophylaxis: When initiating urate-lowering therapy, consider low-dose prednisone (<10 mg/day) as prophylaxis if colchicine and NSAIDs are contraindicated 1, 4

Pitfalls and Caveats

• Blood glucose monitoring: Monitor blood glucose levels in patients with diabetes when using corticosteroids
• Duration: Avoid prolonged corticosteroid use to prevent adverse effects such as fluid retention, mood disorders, and immune suppression 1
• Rebound flares: Be aware that abrupt discontinuation without tapering may lead to rebound flares in some patients
• Avoid in active infections: Corticosteroids should be used cautiously in patients with active infections

Prednisone offers an effective and generally safe option for treating acute gout flares, particularly when NSAIDs or colchicine are contraindicated or poorly tolerated.