What are the indications for steroid use in the treatment of gout (gouty arthritis)?

From the Guidelines

Steroids are indicated for gout when NSAIDs and colchicine are contraindicated, ineffective, or not tolerated, and can be used as first-line therapy in patients without contraindications due to their safety and low-cost profile, as recommended by the American College of Physicians 1.

Indications for Steroid Use in Gout

• Contraindications to NSAIDs and colchicine
• Ineffective NSAIDs and colchicine
• Intolerance to NSAIDs and colchicine
• Polyarticular gout, where systemic steroids are preferred
• Renal insufficiency, heart failure, or gastrointestinal issues where NSAIDs are contraindicated

Recommended Dosage and Administration

• Oral prednisone at 30-40mg daily for 3-5 days, followed by a 7-10 day taper
• Methylprednisolone can be given as an intramuscular injection (40-80mg) or intra-articular injection (20-40mg for large joints, 10-20mg for medium joints) for rapid relief

Mechanism of Action and Side Effects

• Steroids work by suppressing inflammation through inhibition of phospholipase A2 and reduction of inflammatory mediators
• Common side effects include hyperglycemia, mood changes, and fluid retention, so monitoring is necessary, especially in diabetic patients
• Steroids should be used cautiously in patients with uncontrolled diabetes, active infections, or those on anticoagulation therapy

Clinical Guidelines and Recommendations

• The American College of Physicians recommends that clinicians choose corticosteroids, nonsteroidal anti-inflammatory drugs (NSAIDs), or colchicine to treat patients with acute gout, with a strong recommendation and high-quality evidence 1
• The European League Against Rheumatism (EULAR) also recommends the use of corticosteroids, NSAIDs, and colchicine for the treatment of acute gout, with a strong recommendation and high-quality evidence 1

From the FDA Drug Label

Rheumatic Disorders: As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis; B For Intra-articular Or Soft Tissue Administration (See WARNINGS) DEPO-MEDROL is indicated as adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in acute gouty arthritis,

The indications for steroid use in the treatment of gout (gouty arthritis) are:

• Acute gouty arthritis: as adjunctive therapy for short-term administration to tide the patient over an acute episode or exacerbation. This is based on the information provided in the drug label for methylprednisolone (IM) 2.

From the Research

Indications for Steroid Use in Gout Treatment

The use of steroids in the treatment of gout is indicated in certain situations, including:

• When nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine may be hazardous or are not tolerated by the patient 3, 4
• In patients with comorbidities that preclude the use of NSAIDs or colchicine, such as previous or recent gastrointestinal bleeding, anticoagulant therapy, or renal insufficiency 3, 5
• For the treatment of acute mono- or oligoarticular gouty arthritis, intra-articular corticosteroid therapy may be used 5, 4
• In cases of polyarticular attacks, oral corticosteroids or parenteral corticotrophin (ACTH) and corticosteroids may be valuable alternatives 4

Specific Steroid Options

Some specific steroid options mentioned in the studies include:

• Prednisone 3, 4
• Prednisolone 3
• Triamcinolone acetonide 3, 4
• Methylprednisolone acetate 4
• Intra-articular corticosteroids, such as those used for mono- or oligoarticular involvement 5, 4

Important Considerations

When using steroids to treat gout, it is essential to consider the following:

• The potential adverse effects of steroids, particularly in patients with certain comorbidities 3, 5
• The importance of initiating therapy promptly and using an appropriate dose 6, 5
• The need for careful patient education and adequate duration of anti-inflammatory therapy 5