What is the recommended dosing of prednisone (corticosteroid) for the treatment of acute gout?

Prednisone Dosing for Gout

For acute gout attacks, prednisone should be administered 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 and then discontinued, or alternatively given for 2-5 days at full dose followed by tapering for 7-10 days. 1, 2

First-Line Oral Corticosteroid Regimens

• Prednisone or prednisolone at 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 5-10 days is recommended as a first-line treatment option 1, 2
• Alternative regimen: 2-5 days at full dose, followed by tapering for 7-10 days, and then discontinuation 1, 2
• Methylprednisolone dose pack (pre-packaged taper) is an appropriate option according to provider and patient preference 2

Alternative Corticosteroid Administration Routes

• Intra-articular corticosteroid injection is recommended for involvement of 1-2 large joints, with dosing based on joint size 1, 2
• Intramuscular triamcinolone acetonide 60 mg single dose, followed by oral prednisone, is an appropriate alternative regimen 1, 2
• For patients unable to take oral medications, parenteral glucocorticoids (intramuscular or intravenous) are strongly recommended 3

Combination Therapy for Severe Gout Attacks

• For severe acute gout attacks (≥7/10 on pain scale) or polyarticular involvement, consider combination therapy 1, 3
• Appropriate combinations include oral corticosteroids with colchicine, or intra-articular steroids with any other modality 1, 3
• Combination of NSAIDs and systemic corticosteroids is not recommended due to concerns about synergistic gastrointestinal toxicity 1

Monitoring Response and Adjusting Therapy

• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement in pain ≥24 hours after starting therapy 1, 3
• For inadequate response to initial monotherapy, consider switching to another monotherapy or adding a second recommended agent 1
• Continue treatment until the gouty attack has completely resolved 3

Prophylaxis During Urate-Lowering Therapy

• Low-dose prednisone (≤10 mg daily) can be used as a second-line option for prophylaxis during initiation of urate-lowering therapy if colchicine and NSAIDs are not tolerated, contraindicated, or ineffective 1, 3
• Continue prophylaxis for 3-6 months after initiating urate-lowering therapy 3

Important Considerations and Caveats

• Corticosteroids should be considered as first-line therapy in patients without contraindications as they are generally safer and a low-cost treatment option compared to colchicine 2, 3
• Multiple studies have shown that oral corticosteroids are as effective as NSAIDs for treating acute gout, with fewer adverse events 4, 5
• Short-term adverse effects of corticosteroids include dysphoria, mood disorders, elevated blood glucose levels, and fluid retention 2, 3
• For elderly patients with diabetes, more frequent blood glucose monitoring is recommended during the steroid course 4
• Contraindications to corticosteroid use include systemic fungal infections, uncontrolled diabetes, active peptic ulcer disease, and immunocompromised states 2

Evidence Quality

• The American College of Rheumatology provides Level A evidence (highest quality) for the effectiveness of oral corticosteroids in treating acute gout 2
• Recent clinical trials have demonstrated that prednisolone 30-35 mg daily for 5 days is as effective as NSAIDs but with significantly fewer adverse events 5