What are the recommendations for using steroids in the management of acute gout?

Steroid Recommendations for Acute Gout Management

Corticosteroids should be considered as first-line therapy for acute gout flares in patients without contraindications because they are generally safer and a low-cost treatment option compared to NSAIDs and colchicine. 1

First-Line Treatment Options for Acute Gout

The American College of Physicians (ACP) recommends three equally effective first-line options for treating acute gout:

1. Corticosteroids
2. NSAIDs
3. Colchicine

Corticosteroid Regimens

• Oral prednisone/prednisolone: 30-35 mg daily for 3-5 days 2
• Intramuscular injection: Methylprednisolone can be used as adjunctive therapy for acute gouty arthritis 3
• Intra-articular injection: Highly effective for monoarticular gout, especially in large joints 2

Advantages of Corticosteroids

• Safety profile: Fewer adverse effects compared to NSAIDs when used short-term 1, 4
• Efficacy: High-quality evidence shows corticosteroids are as effective as NSAIDs for managing gout 1
• Cost: Generally lower cost than other treatment options, particularly colchicine 1

Clinical Evidence

A randomized clinical trial demonstrated that oral prednisolone (35 mg once daily for 5 days) was equivalent to naproxen (500 mg twice daily for 5 days) in reducing pain in acute gout, with similar minor adverse effects that resolved by 3-week follow-up 4.

Considerations for Steroid Use

Patient Selection

• Preferred in: Patients with contraindications to NSAIDs (renal disease, heart failure, cirrhosis) 1
• Caution in: Patients with diabetes, systemic fungal infections, or known contraindications to corticosteroids 1

Potential Adverse Effects

• Short-term use: Generally well-tolerated 4, 5
• Long-term concerns: Dysphoria, mood disorders, elevated blood glucose, immune suppression, fluid retention 1

Prophylaxis During Urate-Lowering Therapy

For patients starting urate-lowering therapy, low-dose prednisone or prednisolone (≤10 mg/day) can be used for prophylaxis when colchicine or NSAIDs are contraindicated 1, 2. Prophylaxis should continue for:

• At least 6 months, or
• 3 months after achieving target serum urate in patients without tophi, or
• 6 months after achieving target serum urate with resolution of tophi 2

Treatment Algorithm

1. For mild-moderate gout (1-3 small joints or 1-2 large joints):

   • Oral prednisone 30-35 mg daily for 3-5 days 2
   • Alternative: Intra-articular injection for monoarticular involvement 2

2. For severe or polyarticular gout:

   • Consider combination therapy: corticosteroids + colchicine 2

3. For prophylaxis during urate-lowering therapy:

   • Low-dose prednisone (≤10 mg/day) if colchicine or NSAIDs contraindicated 1, 2

Common Pitfalls to Avoid

• Delaying treatment: Initiate within 24 hours of symptom onset 2
• Interrupting urate-lowering therapy during acute flares 2
• Using high-dose steroids for prophylaxis: The American College of Rheumatology considers doses above 10 mg daily inappropriate for most prophylaxis scenarios 1
• Overlooking comorbidities: Consider patient-specific factors when choosing treatment 2

Corticosteroids represent an effective, evidence-based option for managing acute gout, with a favorable short-term safety profile compared to traditional alternatives like NSAIDs and colchicine.