What is the recommended treatment for acute gout attacks in an elderly man using corticosteroids (CS), such as prednisone?

Corticosteroid Treatment for Acute Gout in Elderly Men

Oral prednisone at a dose of 0.5 mg/kg per day (approximately 30-35 mg) for 5 days is the recommended corticosteroid treatment for acute gout attacks in elderly men. 1

First-Line Treatment Options

• Corticosteroids are considered a first-line therapy for acute gout in elderly patients, particularly when NSAIDs and colchicine are contraindicated or poorly tolerated 1, 2
• The American College of Rheumatology recommends oral prednisone at 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 1
• A methylprednisolone dose pack (pre-packaged taper) is also an appropriate option according to provider and patient preference 1

Alternative Administration Routes

• For involvement of only 1-2 large joints, intra-articular corticosteroid injection is recommended, with dose varying depending on joint size 1
• Intramuscular triamcinolone acetonide 60 mg, followed by oral prednisone, is another effective alternative route of administration 1

Why Corticosteroids Are Preferred in the Elderly

• NSAIDs should be used with extreme caution in elderly patients due to risks of gastrointestinal bleeding, renal failure, uncontrolled hypertension, and heart failure 2, 3
• Colchicine is poorly tolerated in the elderly and is best avoided due to increased risk of toxicity, especially in patients with renal impairment 2, 4
• Short-term corticosteroid use poses minimal risk compared to NSAIDs and colchicine in elderly patients with comorbidities 5, 3

Evidence Supporting Corticosteroid Efficacy

• Multiple randomized trials have shown that oral corticosteroids are as effective as NSAIDs for treating acute gout, with fewer adverse events 5
• In one study of 90 patients with acute gout, prednisolone 30 mg/day for 5 days was as effective as indomethacin but with significantly fewer adverse events (27% vs. 63%) 5
• Another study of 120 patients found prednisolone 35 mg/day to be equally effective as naproxen for acute gout, with similar rates of adverse events 5

Dosing Considerations for Elderly Patients

• For elderly patients with renal impairment, corticosteroids do not require dose adjustment, unlike colchicine and many NSAIDs 3, 4
• A starting dose of 30-35 mg of prednisone daily for 5 days is supported by high-quality evidence (Level A) 1
• For severe attacks, consider a slightly higher initial dose with a tapering schedule over 7-10 days 1

Monitoring and Precautions

• Monitor for short-term adverse effects including dysphoria, mood disorders, elevated blood glucose levels, and fluid retention 1
• For elderly patients with diabetes, more frequent blood glucose monitoring is recommended during the steroid course 6
• Avoid long-term corticosteroid use for gout prophylaxis; if needed, use low-dose prednisone (≤10 mg/day) only when colchicine and NSAIDs are contraindicated 5

Treatment Algorithm for Acute Gout in Elderly

1. Assess joint involvement:

   • 1-2 large joints → Consider intra-articular injection 1
   • Polyarticular involvement → Oral prednisone regimen 1

2. Evaluate contraindications to corticosteroids:

   • Systemic fungal infections, uncontrolled diabetes, active peptic ulcer disease 1
   • If contraindications exist, consider alternative approaches 1

3. Select appropriate oral regimen:

   • Standard dosing: Prednisone 30-35 mg daily for 5 days 1
   • Alternative: 2-5 days at full dose followed by tapering for 7-10 days 1

4. Monitor for response:

   • Inadequate response defined as <20% improvement in pain within 24 hours 1
   • If inadequate response, consider combination therapy 1

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 5
• Continue prophylaxis for at least 6 months or until 3 months after achieving target serum urate in patients without tophi 5