What is the role of prednisone (corticosteroid) in treating acute gout attacks?

Role of Prednisone in Treating Acute Gout Attacks

Prednisone is an effective second-line treatment option for acute gout attacks when NSAIDs and colchicine are contraindicated, ineffective, or not tolerated, with oral prednisone 30-35 mg daily for 3-5 days showing comparable efficacy to NSAIDs with potentially fewer gastrointestinal side effects. 1, 2

First-Line Treatment Options for Acute Gout

The American College of Rheumatology guidelines recommend multiple modalities as appropriate initial therapeutic options for acute gout attacks:

1. NSAIDs (e.g., naproxen 500mg twice daily for 5 days)

   • First-line therapy for most patients
   • Contraindicated in patients with renal impairment, peptic ulcer disease, or uncontrolled hypertension 1

2. Colchicine

   • Should be started within 36 hours of symptom onset
   • Low-dose regimen: 1.2 mg initially followed by 0.6 mg one hour later
   • Better safety profile than older high-dose regimens 1

3. Corticosteroids (including prednisone)

   • Oral, intramuscular, or intra-articular routes available
   • Particularly useful when NSAIDs and colchicine are contraindicated 3, 1

Prednisone Dosing for Acute Gout

For acute gout attacks, the evidence supports:

• Oral prednisone 30-35 mg daily for 3-5 days 1, 2
• Alternatively, 30-50 mg initially, gradually tapered over 10 days 4

Efficacy of Prednisone vs. Other Treatments

Moderate-quality evidence indicates that:

• Oral glucocorticoids (including prednisone) and NSAIDs are equally effective for pain relief in acute gout 5, 2
• Pain reduction with prednisone is comparable to NSAIDs both during activity and at rest 2
• Meta-analysis data shows no significant difference in efficacy between prednisolone and NSAIDs during the first 2-6 hours or over the following 4-6 days 2

Safety Considerations

Prednisone may offer safety advantages over NSAIDs in certain populations:

• Reduced withdrawal rates due to adverse events compared to NSAIDs (RR 0.127,95% CI 0.021-0.763) 2
• Decreased risk of gastrointestinal side effects including:
  • Indigestion (RR 0.544,95% CI 0.311-0.952)
  • Nausea (RR 0.296,95% CI 0.136-0.647)
  • Vomiting (RR 0.155,95% CI 0.033-0.722) 2

However, prednisone use comes with important precautions:

• Increased risk of skin rashes (RR 4.049,95% CI 1.241-13.158) 2
• Risk of immunosuppression and increased susceptibility to infections 6
• Potential for HPA axis suppression with prolonged use 6
• Risk of blood pressure elevation, salt and water retention 6

Prednisone for Gout Attack Prophylaxis

For prophylaxis during initiation of urate-lowering therapy (ULT):

• Low-dose prednisone or prednisolone (≤10 mg/day) can be used as an alternative when colchicine and NSAIDs are contraindicated 3
• However, evidence for efficacy of this low-dose strategy is sparse 3
• High daily doses (>10 mg daily) for gout attack prophylaxis are inappropriate in most scenarios 3

Algorithm for Selecting Gout Treatment

1. First-line options (if no contraindications):

   • NSAIDs (naproxen 500mg twice daily) OR
   • Low-dose colchicine (if within 36 hours of symptom onset)

2. Second-line option (if NSAIDs/colchicine contraindicated or not tolerated):

   • Oral prednisone 30-35 mg daily for 3-5 days

3. For severe or polyarticular gout (pain ≥7/10):

   • Consider combination therapy (e.g., colchicine + NSAIDs, oral corticosteroids + colchicine) 1
   • For 1-2 affected joints, intra-articular corticosteroid injection is an option 1

4. For refractory cases:

   • Consider IL-1 inhibitors (anakinra or canakinumab) 1

Common Pitfalls to Avoid

• Using high-dose colchicine regimens (older regimen of continuing until GI side effects develop)
• Failing to provide prophylaxis when initiating urate-lowering therapy
• Stopping prophylaxis too early
• Discontinuing urate-lowering therapy during acute flares 1
• Abrupt discontinuation of prednisone (risk of adrenal insufficiency) 6

Adjunctive Measures

• Topical ice application is recommended alongside pharmacologic therapy 1
• Rest and elevation of the affected joint 1
• Dietary modifications (limit purine-rich foods, alcohol, high-fructose corn syrup) 1

In conclusion, prednisone represents an effective alternative to NSAIDs and colchicine for acute gout management, with comparable efficacy and potentially fewer gastrointestinal side effects in selected patients, though its use must be balanced against the risk of corticosteroid-related adverse effects.