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

Prednisone Dosing for Acute Gout

For acute gout attacks, oral 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 for 2-5 days at full dose followed by tapering for 7-10 days then stopped. 1

Recommended Corticosteroid Regimens

Oral Prednisone Options

• Standard dosing: 0.5 mg/kg per day (typically 30-35 mg daily) 1
• Duration options:
  • 5-10 days at full dose then stop 1
  • 2-5 days at full dose, then taper for 7-10 days, then stop 1
  • 3-5 days at 30-35 mg/day of equivalent prednisolone 1

Alternative Corticosteroid Options

• Methylprednisolone dose pack: An appropriate option according to provider and patient preference 1
• Intramuscular option: Triamcinolone acetonide 60 mg as a single dose, followed by oral prednisone as above 1
• Intra-articular injection: For 1-2 large joints, with dosing based on joint size 1

Clinical Decision Algorithm

1. Assess timing of attack:

   • Initiate treatment as early as possible after symptom onset 1
   • Most effective when started within 36 hours of symptom onset

2. Consider contraindications to other first-line options:

   • Prednisone is particularly appropriate when NSAIDs or colchicine are contraindicated
   • Preferred in patients with renal impairment where NSAIDs and colchicine may be problematic 1

3. Assess number of joints involved:

   • For 1-2 large joints: Consider intra-articular injection (with or without oral therapy) 1
   • For polyarticular involvement: Use oral prednisone 1

4. For severe attacks (≥7/10 on pain scale or polyarticular):

   • Consider combination therapy with colchicine or intra-articular steroids 1
   • Avoid combining systemic corticosteroids with NSAIDs due to increased GI toxicity risk 1

Efficacy and Safety Considerations

• Corticosteroids have comparable efficacy to NSAIDs for pain management in acute gout 2

• Corticosteroids have a more favorable safety profile than NSAIDs with lower risk of:

  • Indigestion (RR 0.50)
  • Nausea (RR 0.25)
  • Vomiting (RR 0.11) 2

• Prednisolone may be more effective than indomethacin in reducing joint swelling 3

Important Caveats

• Monitor response: If inadequate response (<20% improvement in pain within 24 hours or <50% improvement after 24 hours), consider alternative diagnosis or adding a second agent 1

• Short-term use: The recommended dosing is for short-term use only to minimize steroid-related adverse effects 4

• Avoid in active infections: Systemic corticosteroids should be used cautiously in patients with active infections

• Consider prophylaxis: After treating the acute attack, consider prophylaxis during the first 6 months of urate-lowering therapy to prevent recurrent flares 1

The evidence supports that oral prednisone at 0.5 mg/kg per day is an effective and safe option for treating acute gout, with efficacy comparable to NSAIDs but with fewer adverse effects, making it particularly valuable for patients with contraindications to other first-line therapies.