What is the role of prednisone in treating acute gout arthritis?

Prednisone Treatment for Gout Arthritis

Oral corticosteroids such as prednisone (30-35 mg daily for 3-5 days) are recommended as a first-line treatment for acute gout flares, particularly in elderly patients, due to their favorable safety profile in patients with potential comorbidities. 1

First-Line Treatment Options for Acute Gout

The American College of Rheumatology guidelines recommend three first-line therapies for acute gout flares:

1. Oral colchicine
2. NSAIDs
3. Glucocorticoids (including prednisone)

The choice between these options depends on patient-specific factors such as comorbidities and medication contraindications 1.

Prednisone Dosing and Administration

• Standard regimen: Prednisone 30-35 mg daily for 3-5 days 1
• Prednisolone at 35 mg for 5 days is a recommended alternative regimen 1
• No tapering is typically required for short courses

Advantages of Prednisone

• Generally safer and more cost-effective than NSAIDs for treating acute gout flares 1
• Particularly beneficial in:
  • Elderly patients
  • Patients with renal impairment (eGFR < 30 ml/min) where NSAIDs and colchicine are contraindicated 1
  • Patients with history of peptic ulcer disease or GI bleeding
  • Pregnancy (when treatment is necessary) 1

Alternative Corticosteroid Administration Routes

• Intra-articular injections: Particularly effective for 1-2 large joints 1

  • Dosage based on joint size
  • Can be used in combination with other treatments

• Intramuscular administration: Methylprednisolone 0.5-2.0 mg/kg is an option 1

Comparative Efficacy

Research evidence shows that oral prednisolone (35 mg once daily for 5 days) is equally effective as naproxen (500 mg twice daily for 5 days) in treating acute gout arthritis. The difference in pain reduction between the two treatments was minimal (1.3 mm on a 100 mm visual analog scale), with similar minor adverse effects that resolved within 3 weeks 2.

Adjunctive Treatments

• Topical ice is conditionally recommended as an adjuvant treatment for acute gout flares 1
• Combination therapy may be considered for severe polyarticular gout:
  • Corticosteroid + colchicine
  • Intra-articular injections with another modality 1

Important Clinical Considerations

• Begin treatment as soon as possible after symptom onset for optimal effectiveness 3
• Assess renal function before initiating therapy 1
• Consider prophylaxis with colchicine 0.5-1.0 mg daily when initiating urate-lowering therapy to prevent paradoxical flares 1
• Starting allopurinol during an acute gout attack (with appropriate anti-inflammatory prophylaxis) does not significantly prolong the duration of the attack 4

Common Pitfalls to Avoid

1. Delaying treatment: The most important determinant of therapeutic success is how soon therapy is initiated 3
2. Inadequate dosing: Using too low a dose of prednisone may result in incomplete resolution
3. Failing to address underlying hyperuricemia: After treating the acute attack, consider urate-lowering therapy for patients with recurrent attacks (≥2 per year), tophi, joint damage, or chronic kidney disease 1
4. Neglecting lifestyle modifications: Advise patients to limit purine-rich foods, alcohol (especially beer), and high-fructose corn syrup beverages 1