What is the recommended prednisone (corticosteroid) taper for treating gout?

Recommended Prednisone Taper for Gout

For treating acute gout attacks, oral prednisone should be administered at a starting dose of 0.5 mg/kg per day for 5-10 days at full dose and then stopped, or alternatively given for 2-5 days at full dose followed by tapering for 7-10 days and then discontinued. 1

Initial Corticosteroid Dosing Options

Oral Prednisone Regimens

• Starting dose of 0.5 mg/kg per day (approximately 30-35 mg for average adults) 1
• Duration options:
  • 5-10 days at full dose then stop 1
  • 2-5 days at full dose, followed by tapering for 7-10 days, then stop 1
  • Methylprednisolone dose pack (pre-packaged taper) is also an appropriate option according to provider and patient preference 1

Alternative Corticosteroid Administration Routes

• Intra-articular: Dose varies depending on joint size (can be used with or without oral therapy) - recommended for involvement of 1-2 large joints 1
• Intramuscular: Triamcinolone acetonide 60 mg, followed by oral prednisone as described above 1

Evidence Quality and Recommendations

The American College of Rheumatology (ACR) guidelines provide the strongest evidence for prednisone dosing in gout, with oral corticosteroids having Level A evidence (highest quality) for effectiveness 1. Prednisolone at 35 mg for 5 days has been successfully used to treat acute gout with fewer adverse effects than NSAIDs 1.

Clinical Decision Making Algorithm

1. Assess contraindications to corticosteroids 1:

   • Systemic fungal infections
   • Uncontrolled diabetes
   • Active peptic ulcer disease
   • Immunocompromised state

2. Consider joint involvement 1:

   • For 1-2 large joints: Consider intra-articular injection (with or without oral therapy)
   • For polyarticular involvement: Use oral prednisone regimen

3. Select appropriate oral regimen based on attack severity 1:

   • Severe attacks: Higher end of dosing range (0.5 mg/kg)
   • Moderate attacks: Standard dosing (30-35 mg daily)

4. Monitor for response 1:

   • Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement at 24 hours
   • Consider combination therapy for severe attacks not responding to monotherapy

Important Considerations and Caveats

• Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer and a low-cost treatment option compared to colchicine 1
• For severe acute gout attacks (pain score ≥7/10) or polyarticular involvement, consider combination therapy with colchicine and oral corticosteroids 1
• Adverse effects associated with short-term corticosteroid use include dysphoria, mood disorders, elevated blood glucose levels, and fluid retention 1
• The European League Against Rheumatism (EULAR) recommends oral prednisolone at 30-35 mg/day for 3-5 days as an appropriate first-line option 1
• A short course of oral corticosteroid therapy can be effective for acute gout when NSAIDs are contraindicated 2
• For prophylaxis during initiation of urate-lowering therapy, low-dose prednisone (<10 mg/day) can be used as a second-line option if colchicine and NSAIDs are not tolerated, contraindicated, or ineffective 1, 3