What is the recommended prednisone (corticosteroid) course for a patient with an acute gout attack?

Prednisone Course for Acute Gout Attack

For acute gout attacks, oral prednisone should be administered at 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 a 7-10 day taper. 1, 2

Treatment Algorithm for Acute Gout

First-Line Corticosteroid Options:

• Oral Prednisone:

  • Dosage: 0.5 mg/kg per day
  • Duration options:
    1. 5-10 days at full dose then stop, OR
    2. 2-5 days at full dose followed by a 7-10 day taper 1, 2
  • Alternative: Methylprednisolone Dose Pack with appropriate follow-up 1

• Injectable Options:

  • Intra-articular: Dose varies depending on joint size (can be used with or without oral therapy) 1
  • Intramuscular: Triamcinolone Acetonide 60 mg, followed by oral prednisone as above 1

When to Choose Prednisone Over Other Options:

• First-line in patients with:

  • Renal disease
  • Heart failure
  • Cirrhosis
  • Contraindications to NSAIDs or colchicine 2

• Avoid in patients with:

  • Uncontrolled diabetes
  • Uncontrolled hypertension (consider NSAIDs or colchicine instead) 2

Combination Therapy for Severe Attacks

• For severe or polyarticular gout attacks, consider combination therapy:
  • Oral corticosteroids + colchicine
  • Intra-articular steroids + any other modality 1, 2

Clinical Evidence and Considerations

• Randomized trials have demonstrated that oral prednisone (35 mg daily for 5 days) is equivalent to naproxen for pain reduction in acute gout 3
• Prednisone is particularly valuable when NSAIDs are contraindicated 4
• A 2024 trial (COPAGO) is comparing prednisolone 30 mg for 5 days with low-dose colchicine for acute gout, but results are not yet available 5

Monitoring and Safety

• Monitor for potential adverse effects with corticosteroid use:
  • Elevated blood glucose (especially in diabetic patients)
  • Blood pressure changes
  • Mood disorders/dysphoria
  • Immune suppression 2
• Short-term use (5-10 days) generally has minimal side effects when used for acute gout 4

Important Caveats

• Do not interrupt urate-lowering therapy during an acute attack 2
• Treatment should be initiated as soon as possible, ideally within 24 hours of symptom onset 2
• For long-term management, prophylaxis should be considered when initiating urate-lowering therapy 1, 2
• While evidence supports both fixed-duration and tapered approaches to prednisone therapy, there is no definitive evidence showing superiority of one approach over the other 1, 6

Prednisone represents an effective, evidence-based treatment option for acute gout attacks, particularly in patients with contraindications to NSAIDs or colchicine, with comparable efficacy and a favorable short-term safety profile.