What is the recommended prednisone (corticosteroid) taper schedule for a patient with gout?

Prednisone Taper for Gout

For acute gout, prednisone should be started at 0.5 mg/kg per day for 5-10 days at full dose then stopped, OR for 2-5 days at full dose followed by a 7-10 day taper. 1

Initial Corticosteroid Treatment Options

Corticosteroids are an excellent first-line option for treating acute gout attacks, especially in patients with contraindications to NSAIDs or colchicine. The American College of Rheumatology (ACR) guidelines provide specific recommendations for prednisone dosing:

Oral Prednisone Protocol:

• Starting dose: 0.5 mg/kg per day
• Duration options:
  1. 5-10 days at full dose then stop (no taper)
  2. 2-5 days at full dose followed by a 7-10 day taper

Alternative Corticosteroid Options:

• Methylprednisolone Dose Pack: A pre-packaged taper regimen
• Intramuscular option: Triamcinolone acetonide 60 mg, followed by oral prednisone as above
• Intra-articular injection: Dosage varies depending on joint size (can be used with or without oral therapy)

Rationale for Corticosteroid Use

Corticosteroids should be considered as first-line therapy for acute gout in patients without contraindications because:

• They are generally safer than alternatives 1
• They are cost-effective
• They are as effective as NSAIDs for managing gout with fewer adverse effects
• A short course (as recommended above) rarely causes significant steroid-related complications

Prophylaxis During Urate-Lowering Therapy

When initiating urate-lowering therapy (ULT), anti-inflammatory prophylaxis is strongly recommended to prevent gout flares:

• First-line prophylaxis: Low-dose colchicine (0.6 mg once or twice daily)
• Second-line prophylaxis (if colchicine is not tolerated or contraindicated): Low-dose prednisone (<10 mg/day) 1

Duration of Prophylaxis:

• Continue prophylaxis for 3-6 months after initiating ULT 1
• Longer duration may be needed if the patient continues to experience flares

Important Clinical Considerations

1. Starting dose adjustment: In patients with renal impairment, consider lower starting doses of prednisone.

2. Monitoring: Watch for potential short-term side effects including dysphoria, mood disorders, elevated blood glucose levels, and fluid retention.

3. Contraindications: Systemic fungal infections and other specific contraindications to corticosteroid therapy.

4. Combination therapy: For severe acute gout attacks, especially with multiple large joint involvement or polyarticular arthritis, combination therapy may be appropriate, including oral corticosteroids with colchicine 1.

5. Timing of ULT initiation: ULT can be started during an acute gout attack (with appropriate anti-inflammatory coverage) rather than waiting for resolution 1.

Practical Taper Example

For a 70 kg patient requiring a taper:

1. Initial dose: 35 mg prednisone daily (0.5 mg/kg) for 3 days
2. Then 25 mg daily for 2 days
3. Then 20 mg daily for 2 days
4. Then 15 mg daily for 2 days
5. Then 10 mg daily for 2 days
6. Then 5 mg daily for 2 days, then stop

This approach provides effective anti-inflammatory coverage while minimizing the risk of rebound flares that can occur with abrupt discontinuation.