What is the best management plan for a patient with acute gout who has completed their initial prednisone course and continues to experience pain?

Management of Acute Gout with Persistent Pain After Initial Treatment

For a patient with acute gout who has completed their initial prednisone course but continues to experience pain, the best approach is to prescribe a 5-10 day course of oral prednisone at 0.5 mg/kg per day until complete resolution of symptoms.

Assessment of Current Situation

The patient has:

• Third episode of gout, currently affecting the right great toe (first MTP joint)
• Partial improvement with initial treatment (prednisone and colchicine)
• Ran out of prednisone due to dosing confusion (took twice daily instead of once daily)
• Persistent pain despite some reduction in swelling
• No known renal impairment (though baseline renal function is unknown)
• No known allergies
• Otherwise fit and well, but is a current smoker

Treatment Recommendations

Immediate Management

1. Complete the Prednisone Course:

   • Prescribe prednisone 0.5 mg/kg per day for 5-10 days at full dose until complete resolution 1
   • Alternative regimen: 2-5 days at full dose followed by tapering for 7-10 days 1

2. Continue Colchicine:

   • Since the patient is already on colchicine, continue at 0.6 mg once or twice daily until the attack completely resolves 1
   • Note: Colchicine is most effective when started within 36 hours of symptom onset, but can still provide benefit as continuation therapy

If Pain Persists Despite Above Measures

If inadequate response (defined as <20% improvement in pain within 24 hours or <50% improvement after 24 hours) 1:

1. Consider combination therapy:

   • Add an NSAID (if no contraindications) along with colchicine 1
   • Or increase prednisone dose if NSAIDs are contraindicated

2. Consider intra-articular corticosteroid injection:

   • Direct injection into the affected first MTP joint can provide rapid relief 1

Rationale for Recommendation

Oral corticosteroids are recommended as first-line therapy for acute gout due to their:

• Effectiveness comparable to NSAIDs but with fewer adverse effects 1, 2
• High-quality evidence supporting their use 1, 3
• Appropriate option for patients who have already shown partial response to this treatment

Multiple studies have demonstrated that prednisolone (35 mg daily for 5 days) is as effective as NSAIDs for managing gout with fewer adverse effects 1, 3. The American College of Rheumatology guidelines strongly support using prednisone at 0.5 mg/kg per day for 5-10 days 1, 2.

Important Considerations

Dosing Clarification

• Ensure the patient understands the correct dosing regimen to prevent future confusion
• Provide written instructions on the tapering schedule if applicable

Monitoring

• Assess response to treatment within 24-48 hours
• Monitor for potential corticosteroid side effects (though these are minimal with short-term use)
• Consider checking renal function if prolonged NSAID or colchicine use is anticipated

Long-term Management

After resolution of the acute attack:

• Since this is the patient's third episode, consider urate-lowering therapy (e.g., allopurinol) 1
• If initiating urate-lowering therapy, continue prophylaxis with low-dose colchicine (0.6 mg once or twice daily) or low-dose prednisone (<10 mg/day) for at least 6 months 1

Common Pitfalls to Avoid

1. Inadequate duration of treatment: Ensure complete resolution of the attack before stopping treatment
2. Inappropriate dosing: Avoid excessive or insufficient dosing of prednisone
3. Failure to provide prophylaxis: If initiating urate-lowering therapy, prophylaxis is essential to prevent flares
4. Overlooking renal function: Adjust colchicine dosing if renal impairment is present
5. Using NSAIDs without gastroprotection: If adding NSAIDs, consider gastroprotection in high-risk patients

By following these recommendations, the patient's acute gout attack should resolve completely, improving both pain and function.