What is the recommended intramuscular (IM) injection for a gout flare?

Intramuscular Injection for Gout Flare

For an acute gout flare requiring intramuscular injection, use intramuscular methylprednisolone at an initial dose of 0.5–2.0 mg/kg (approximately 40-140 mg for most adults) or intramuscular triamcinolone acetonide 60 mg. 1

Primary IM Corticosteroid Options

The 2020 American College of Rheumatology guidelines strongly recommend glucocorticoids (including intramuscular formulations) as appropriate first-line therapy for gout flares, with high-quality evidence supporting their use. 1

Specific IM Dosing Recommendations:

• Intramuscular methylprednisolone: 0.5–2.0 mg/kg as initial dose 1

  • This translates to approximately 40-140 mg for a 70-80 kg adult
  • Can be repeated as clinically indicated 1

• Intramuscular triamcinolone acetonide: 60 mg as a single injection 2, 3

  • May be followed by oral prednisone if needed 2
  • A second injection can be given on Day 1-2 if inadequate response 3
  • Clinical improvement typically occurs by Day 3-4 in most patients 3

When to Use IM Injection

IM corticosteroids are particularly indicated when:

• Patient is NPO (nothing by mouth) due to surgical or medical conditions 1
• Oral medications cannot be tolerated or absorbed 1
• Rapid pain relief is needed and oral access is limited 1
• Polyarticular involvement makes intra-articular injection impractical 3

For NPO patients specifically, the 2020 ACR guidelines strongly recommend glucocorticoids (intramuscular, intravenous, or intra-articular) over IL-1 inhibitors or ACTH, with high-quality evidence. 1

Clinical Decision Algorithm

Step 1: Assess contraindications to corticosteroids 2, 4

• Active systemic infection or high infection risk
• Uncontrolled diabetes (relative contraindication requiring glucose monitoring)
• Active peptic ulcer disease
• Systemic fungal infections

Step 2: Determine route based on clinical scenario 1, 2

• If 1-2 large joints involved and patient can tolerate procedure → intra-articular injection preferred
• If polyarticular involvement or patient NPO → IM or IV corticosteroids
• If oral route available → oral prednisone 0.5 mg/kg/day (30-35 mg) for 5-10 days

Step 3: Select IM agent and dose 1, 2, 3

• Methylprednisolone 0.5–2.0 mg/kg IM (use higher end for severe attacks)
• OR triamcinolone acetonide 60 mg IM

Step 4: Monitor response 2, 3

• Expect major improvement by 24-72 hours
• If inadequate response (<50% improvement at 24 hours), consider second injection or switch to combination therapy
• Monitor blood glucose in diabetic patients 2, 4

Important Clinical Considerations

Advantages of IM corticosteroids over alternatives:

• Safer and lower cost compared to IL-1 inhibitors 2
• Effective when NSAIDs contraindicated (renal disease, heart failure, peptic ulcer disease, anticoagulation) 1
• Effective when colchicine contraindicated (severe renal or hepatic disease) 1
• Single injection often sufficient for complete resolution 2, 3

Common pitfalls to avoid:

• Do not use IM ketorolac as monotherapy—there was no consensus supporting this approach in the 2012 ACR guidelines 1
• Do not use intramuscular triamcinolone acetonide as monotherapy without evidence of efficacy—the 2012 ACR task force found no consensus for this as standalone therapy, though the 60 mg dose followed by oral prednisone is supported 1, 2
• Monitor for short-term adverse effects including dysphoria, mood changes, hyperglycemia, and fluid retention 2, 4
• In elderly patients with diabetes, increase frequency of blood glucose monitoring during treatment 4

Evidence quality note: The recommendation for IM methylprednisolone carries Evidence B grade from the 2012 ACR guidelines, while the overall recommendation for glucocorticoids (including IM route) in the 2020 ACR guidelines has high-quality evidence. 1