Can I prescribe prednisone for a patient with impaired renal function (eGFR 55) experiencing an acute gout attack?

Prednisone for Acute Gout Attack in a Patient with eGFR 55

Yes, prednisone is an appropriate and safe treatment option for an acute gout attack in a patient with moderate renal impairment (eGFR 55). 1

Treatment Options for Acute Gout with Renal Impairment

The 2020 American College of Rheumatology (ACR) guidelines strongly recommend several anti-inflammatory options for acute gout attacks, with the specific choice guided by patient factors:

1. Oral corticosteroids (prednisone/prednisolone)

   • Safe and effective in patients with renal impairment
   • Recommended dose: typically 0.5 mg/kg/day for 5-10 days, then taper
   • No dose adjustment needed for eGFR 55 1

2. NSAIDs

   • Use with caution in renal impairment
   • Higher risk of worsening kidney function
   • Not preferred with eGFR <60 ml/min 1, 2

3. Colchicine

   • Requires dose reduction in renal impairment
   • Higher risk of toxicity with decreased renal function
   • Complicated by potential drug interactions 1, 2

Why Prednisone is Appropriate in This Case

For a patient with eGFR 55 (moderate renal impairment), prednisone offers several advantages:

• Safety profile: Prednisone doesn't require dose adjustment for this level of renal impairment 1
• Efficacy: Corticosteroids have demonstrated similar efficacy to NSAIDs for acute gout attacks 1, 3
• Renal protection: Unlike NSAIDs, prednisone doesn't further compromise renal function 2, 4
• Guideline support: The ACR guidelines specifically mention prednisone/prednisolone as appropriate anti-inflammatory therapy for acute gout 1

Dosing Recommendations

• Initial dose: 30-50 mg daily 3
• Duration: Taper over 7-10 days to prevent rebound attacks 1, 3
• Monitoring: Watch for short-term side effects (hyperglycemia, mood changes, insomnia)

Important Considerations

• Short-term use: The risks of corticosteroid complications are minimal with short courses used for acute gout 3
• Prophylaxis: If initiating urate-lowering therapy (ULT), consider continuing low-dose prednisone (≤10 mg/day) as prophylaxis for 3-6 months 1
• Avoid high-dose long-term use: The ACR guidelines caution against using high doses (>10 mg daily) for long-term prophylaxis 1

Common Pitfalls to Avoid

1. Stopping too quickly: Abrupt discontinuation may lead to rebound attacks
2. Inadequate dosing: Underdosing may result in incomplete resolution
3. Neglecting concurrent ULT: Consider starting ULT during the acute attack if indicated 1
4. Missing comorbidities: Monitor blood glucose in diabetic patients

In conclusion, prednisone is a safe and effective option for treating acute gout attacks in patients with moderate renal impairment (eGFR 55), with the advantage of not requiring dose adjustment and not further compromising kidney function.