Oral Steroid Indications and Regimens for Gout
Oral prednisone at a dose of 0.5 mg/kg per day for 5-10 days at full dose then stopped, or for 2-5 days at full dose followed by tapering for 7-10 days, is indicated for acute gout attacks when NSAIDs or colchicine are contraindicated, not tolerated, or ineffective. 1, 2
Indications for Oral Steroids in Acute Gout
- Oral corticosteroids are appropriate first-line therapy for acute gout attacks when NSAIDs or colchicine are contraindicated, not tolerated, or ineffective 2, 3
- Specific contraindications to NSAIDs include renal disease, heart failure, or cirrhosis 4
- Contraindications to colchicine include severe renal or hepatic impairment and significant drug interactions 1
- Oral steroids are particularly useful in polyarticular gout attacks affecting multiple joints 2
- Oral steroids can be considered as initial monotherapy or as part of combination therapy for severe acute gout attacks 1
Recommended Oral Steroid Regimens for Acute Gout
- Prednisone 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 5-10 days at full dose then stopped 1, 2
- Alternative regimen: Prednisone 0.5 mg/kg per day for 2-5 days at full dose followed by tapering for 7-10 days 1, 2
- Methylprednisolone dose pack (pre-packaged taper) is an appropriate alternative option 2
- For severe acute attacks, particularly with multiple large joint involvement or polyarticular arthritis, combination therapy with oral steroids and colchicine can be considered 1, 2
Oral Steroids for Gout Attack Prophylaxis
- Low-dose prednisone (≤10 mg/day) can be used as a second-line prophylactic option when initiating urate-lowering therapy 1, 5
- Oral steroid prophylaxis is indicated when colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1
- Prophylaxis should be continued for the greater of: 6 months duration, or 3 months after achieving target serum urate for patients without tophi, or 6 months after achieving target serum urate if tophi are present 1, 6
- Caution is advised with prolonged steroid prophylaxis due to potential adverse effects 1
Monitoring and Safety Considerations
- Short-term adverse effects of oral steroids may include dysphoria, mood disorders, elevated blood glucose levels, and fluid retention 2
- Absolute contraindications to systemic corticosteroids include systemic fungal infections, uncontrolled diabetes, active peptic ulcer disease, and immunocompromised state 2
- Monitor for adequate response, defined as ≥20% improvement in pain within 24 hours or ≥50% improvement at 24 hours 2
- If response is inadequate, consider adding another agent for combination therapy 1, 2
- Short courses of oral steroids (5-10 days) for acute gout attacks generally have minimal serious adverse effects 7, 8
Alternative Corticosteroid Administration Routes
- Intra-articular corticosteroid injection is recommended for involvement of 1-2 large joints, with dose varying depending on joint size 1, 2
- Intramuscular triamcinolone acetonide 60 mg, followed by oral prednisone, is an effective alternative route of administration 1, 2
- These alternative routes may be considered when oral administration is not feasible or when targeting specific affected joints 2