Can steroids help manage an acute gout flare?

Steroids for Acute Gout Flare Management

Corticosteroids should be considered as first-line therapy for acute gout flares in patients without contraindications because they are generally safer, highly effective, and a low-cost treatment option. 1

Evidence-Based Treatment Options for Acute Gout

High-quality evidence supports three effective medication classes for treating acute gout flares:

1. Corticosteroids

   • Recommended as first-line therapy by the American College of Physicians (ACP) 1
   • Prednisolone 35 mg for 5 days has been successfully used 1
   • As effective as NSAIDs but with fewer adverse effects 1

2. NSAIDs

   • Equally effective regardless of specific NSAID chosen 1
   • Higher risk of adverse effects compared to steroids 1
   • Contraindicated in patients with renal disease, heart failure, or cirrhosis 1

3. Colchicine

   • Effective but should be used at low doses (1.2 mg followed by 0.6 mg 1 hour later) 1
   • More expensive than NSAIDs or corticosteroids 1
   • Associated with more gastrointestinal side effects 1

Why Steroids Are Often Preferred

Steroids offer several advantages for acute gout management:

• Efficacy: Among the most effective anti-inflammatory medications available 1
• Safety profile: Generally safer than NSAIDs for short-term use 1, 2
• Cost-effectiveness: Lower cost than colchicine 1
• Versatility: Can be used when NSAIDs are contraindicated 2

A short course of oral prednisone (30-50 mg initially, tapered over 10 days) typically results in clinical resolution without rebound arthropathy or steroid complications 2.

Treatment Algorithm for Acute Gout

1. Assess for contraindications to steroids:

   • Systemic fungal infections
   • Known contraindications to steroids

2. If no contraindications to steroids:

   • Initiate prednisolone 35 mg daily for 5 days 1
   • Alternative: Prednisone 30-50 mg initially, tapered over 10 days 2

3. If steroids contraindicated:

   • Consider NSAIDs if no renal disease, heart failure, or cirrhosis
   • Consider low-dose colchicine (1.2 mg followed by 0.6 mg 1 hour later) if NSAIDs contraindicated 1

Important Considerations and Pitfalls

• Short-term use: The adverse effects associated with steroids (dysphoria, mood disorders, elevated blood glucose, immune suppression, fluid retention) are primarily concerns with long-term use 1

• Avoid high-dose colchicine: Higher doses of colchicine (1.2 mg followed by 0.6 mg/h for 6 hours) offer no additional benefit but cause more gastrointestinal adverse effects 1

• Don't initiate urate-lowering therapy during acute flare: This is for long-term management after the acute phase 1

• Monitoring: No need to monitor serum urate levels during acute flare treatment 1

The ACP's strong recommendation with high-quality evidence supports that corticosteroids, NSAIDs, and colchicine are all effective for acute gout, but steroids offer the best balance of efficacy, safety, and cost for most patients 1.