Can I add 20mg of prednisone once daily for another 5 days to the current regimen for a patient with gout who has shown mild improvement?

Managing Gout with Prednisone: Adding a Taper Regimen

Yes, adding prednisone 20mg once daily for another 5 days is appropriate for a patient with gout who has shown only mild improvement after a 5-day course of prednisone 20mg BID.

Rationale for Prednisone Taper

Corticosteroids are highly effective for treating acute gout flares and are considered first-line therapy in many patients 1. The current situation represents a partially responsive gout flare that requires extension of therapy with a tapering dose.

Evidence Supporting This Approach:

• High-quality evidence shows that corticosteroids effectively reduce pain in patients with acute gout 1
• Prednisone at doses of 30-50mg initially, gradually tapered over 10 days, results in clinical resolution without rebound arthropathy in most patients 2
• For acute gout, a common effective regimen is prednisone 30mg daily for 5 days 1
• When higher initial doses (up to 60mg) are used, tapering is recommended to avoid withdrawal symptoms 3

Treatment Algorithm for Partially Responsive Gout

1. Initial treatment (completed): Prednisone 20mg BID for 5 days
2. Taper phase (recommended): Prednisone 20mg once daily for 5 days
3. Monitoring: Assess for complete resolution of pain, swelling, and redness

This approach follows the principle that after a favorable response, the proper maintenance dosage should be determined by decreasing the initial drug dosage in small increments at appropriate time intervals 3.

Benefits of Tapering Approach

• Prevents rebound inflammation
• Allows gradual withdrawal of corticosteroid therapy
• Reduces risk of adrenal suppression
• Provides continued anti-inflammatory effect while inflammation resolves

Potential Side Effects to Monitor

• Blood glucose elevation (particularly important in diabetic patients) 4
• Fluid retention
• Mood changes
• Sleep disturbances
• Increased blood pressure

Alternative Options (If Prednisone Taper Fails)

If symptoms persist despite the taper:

1. Consider adding colchicine: Low-dose colchicine (0.6mg once or twice daily) can be added for better control 4
2. Consider NSAIDs: If no contraindications exist (renal disease, heart failure, cirrhosis) 1
3. Consider intra-articular injection: For persistent single joint involvement 4

Long-Term Management Considerations

After resolving the acute flare:

• Consider urate-lowering therapy (ULT) if this is a recurrent attack 1
• If starting ULT, provide prophylaxis with low-dose colchicine or prednisone for 3-6 months 1, 4
• Start allopurinol at low dose (≤100mg/day) with subsequent dose titration if ULT is indicated 1

Conclusion

The proposed regimen of adding prednisone 20mg once daily for 5 days represents an appropriate taper strategy for a patient with gout who has shown only mild improvement after the initial treatment course. This approach is supported by clinical guidelines and evidence on the management of acute gout flares.