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

Intramuscular Glucocorticoid for Gout Flare

For an acute gout flare requiring intramuscular injection, use intramuscular triamcinolone acetonide 60 mg as the best option, which can be followed by oral prednisone if needed. 1

Primary IM Recommendation

• Intramuscular triamcinolone acetonide 60 mg is the specifically recommended IM glucocorticoid dose for acute gout flares according to the 2020 American College of Rheumatology guidelines 2, 1
• This can be administered as a single injection, with the option to follow with oral prednisone for continued anti-inflammatory effect 1
• Alternative dosing: IM methylprednisolone can be used at 0.5-2.0 mg/kg (approximately 40-140 mg for most adults), with the option to repeat as clinically indicated 1

When IM Injection is Particularly Indicated

• IM glucocorticoids are strongly recommended as first-line therapy when patients are NPO (nothing by mouth) due to surgical or medical conditions 2, 1
• Use IM route when oral medications cannot be tolerated or absorbed 1
• Consider IM injection when rapid pain relief is needed and oral access is limited 1
• IM glucocorticoids are appropriate when NSAIDs are contraindicated (renal disease, heart failure, peptic ulcer disease, anticoagulation) 1

Evidence Quality

• The American College of Rheumatology provides a strong recommendation for glucocorticoids (including IM route) as first-line therapy for gout flares, with high-quality evidence supporting their use 2, 1
• IM triamcinolone acetonide 60 mg has been prospectively studied and shown to be safe, well-tolerated, and effective, with major clinical improvement occurring by Day 1-4 in most patients 3
• IM methylprednisolone carries an Evidence B grade according to ACR guidelines 1

Advantages Over Alternative Therapies

• IM glucocorticoids are safer and lower cost compared to IL-1 inhibitors (canakinumab, rilonacept), which the ACR strongly recommends against as first-line therapy 2, 1
• The ACR strongly recommends glucocorticoids over ACTH for gout flares 2
• Short-term glucocorticoid use has fewer adverse effects compared to NSAIDs in many patient populations 1

Clinical Algorithm for IM Glucocorticoid Use

Step 1: Assess oral medication feasibility

• If patient is NPO or cannot tolerate oral medications → proceed with IM injection 1
• If oral route is available → consider oral prednisone 0.5 mg/kg/day (30-35 mg for average adults) for 5-10 days instead 1, 4

Step 2: Assess joint involvement

• If 1-2 large joints involved → consider intra-articular injection as alternative to IM 2, 1
• If polyarticular involvement or small joints → IM triamcinolone acetonide 60 mg is preferred 1

Step 3: Administer IM glucocorticoid

• Give triamcinolone acetonide 60 mg IM as single injection 2, 1
• Alternative: methylprednisolone 40-140 mg IM (0.5-2.0 mg/kg) 1

Step 4: Follow-up plan

• Consider transitioning to oral prednisone after IM injection for continued effect 1
• Monitor for response within 24-48 hours 1
• If inadequate response (<20% pain improvement at 24 hours), consider combination therapy or alternative diagnosis 1

Important Caveats and Monitoring

• Screen for contraindications before administering: systemic fungal infections, uncontrolled diabetes, active peptic ulcer disease, immunocompromised state 1
• Short-term adverse effects include dysphoria, mood disorders, elevated blood glucose, and fluid retention 1, 4
• For patients with diabetes, increase blood glucose monitoring frequency during treatment 4
• The IM route avoids gastrointestinal side effects associated with oral NSAIDs and colchicine 1
• Do not use IM glucocorticoids for long-term gout prophylaxis; reserve low-dose oral prednisone (<10 mg/day) only when colchicine and NSAIDs are contraindicated 1, 4