What is a suitable prednisone (corticosteroid) regimen for an acute gout attack?

Prednisone Regimens for Acute Gout Attack

For an acute gout attack, oral prednisone at a starting dose of 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 5-10 days at full dose, followed by discontinuation, is the recommended corticosteroid regimen. 1, 2

Primary Oral Prednisone Options

• Option 1 (Highest Evidence): Prednisone or prednisolone at 0.5 mg/kg per day (approximately 30-35 mg) for 5-10 days at full dose, then discontinue 1, 2
• Option 2: Prednisone or prednisolone at full dose for 2-5 days, followed by tapering for 7-10 days, then discontinue 1
• Option 3: Methylprednisolone dose pack (pre-packaged taper) is an appropriate alternative according to provider and patient preference 1, 2

Alternative Corticosteroid Administration Routes

• For 1-2 large joints: Intra-articular corticosteroid injection is recommended, with dosing based on joint size 1
• Intramuscular option: Single dose of triamcinolone acetonide 60 mg, followed by oral prednisone as above 1
• Combination therapy: Intra-articular steroids can be used in combination with oral corticosteroids, NSAIDs, or colchicine for severe attacks 1, 2

Clinical Decision Algorithm

1. Assess joint involvement:

   • 1-2 large joints: Consider intra-articular injection 1
   • Polyarticular involvement: Use oral prednisone regimen 1, 2

2. Assess attack severity:

   • Severe attack (pain ≥7/10): Consider combination therapy 1
   • Moderate attack: Standard oral prednisone regimen 1, 2

3. Monitor response:

   • Inadequate response = <20% improvement in pain within 24 hours or <50% improvement at ≥24 hours 1
   • If inadequate response: Consider switching to another monotherapy or adding a second agent 1

Evidence and Efficacy

• Oral corticosteroids have Level A evidence (highest quality) for effectiveness in treating acute gout 1, 2
• A randomized trial showed prednisolone 35 mg daily for 5 days is equally effective as naproxen for gout arthritis 3
• Corticosteroids should be considered as first-line therapy in patients without contraindications due to safety profile and low cost 1, 2

Important Considerations

• Short-term adverse effects may include dysphoria, mood disorders, elevated blood glucose levels, and fluid retention 1, 2
• Contraindications include systemic fungal infections, uncontrolled diabetes, and immunocompromised states 2
• For severe attacks or polyarticular involvement, consider combination therapy with colchicine and oral corticosteroids 1, 2
• Oral corticosteroids are particularly useful when NSAIDs are contraindicated 4, 5

Prophylaxis During Urate-Lowering Therapy

• 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 1, 2