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

Prednisone Dosing for Acute Gout

For acute gout, give prednisone 0.5 mg/kg per day (approximately 30-40 mg for most adults) for 5-10 days at full dose then stop, or alternatively give for 2-5 days at full dose followed by a taper over 7-10 days. 1, 2

Initial Dosing Regimen

The American College of Rheumatology provides two evidence-based approaches:

• Option 1 (No taper): Prednisone 0.5 mg/kg per day for 5-10 days at full dose, then discontinue abruptly (Evidence Level A) 1, 2

• Option 2 (With taper): Prednisone 0.5 mg/kg per day for 2-5 days at full dose, then taper over 7-10 days before discontinuation (Evidence Level C) 1, 2

• Option 3 (Convenience): Methylprednisolone dose pack is an acceptable alternative based on provider and patient preference (Evidence Level C) 1, 2

The 0.5 mg/kg dosing translates to approximately 30-35 mg daily for average-sized adults, which has been validated in multiple randomized trials showing equivalence to NSAIDs with fewer adverse events. 1, 2

Alternative Routes of Administration

For monoarticular or oligoarticular involvement (1-2 large joints):

• Intra-articular corticosteroid injection is recommended, with dose varying by joint size (Evidence Level B) 1, 2
• Can be combined with oral therapy for severe attacks 1

For patients unable to take oral medications:

• Intramuscular triamcinolone acetonide 60 mg as a single dose, followed by oral prednisone as above 1, 2
• Note: IM triamcinolone acetonide as monotherapy lacks consensus 1

When to Use Combination Therapy

For severe attacks (pain ≥7/10) or polyarticular involvement:

• Initial combination therapy with full-dose oral corticosteroids plus prophylactic-dose colchicine is appropriate (Evidence Level C) 1
• Intra-articular steroids can be combined with any other oral modality 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Monitoring for Treatment Response

Define inadequate response as:

• <20% improvement in pain within 24 hours, OR
• <50% improvement in pain at ≥24 hours 1

If inadequate response occurs:

• Consider alternative diagnoses to gout 1
• Switch to another monotherapy (NSAID or colchicine) 1
• Add a second agent from the recommended options 1

Important Clinical Considerations

Corticosteroids are particularly advantageous when:

• NSAIDs are contraindicated (renal disease, heart failure, peptic ulcer disease, anticoagulation) 2, 3
• Colchicine is contraindicated or not tolerated 1
• Patient has multiple comorbidities common in elderly populations 4

Evidence quality: Multiple randomized trials demonstrate that prednisolone 30-35 mg daily for 5 days is as effective as NSAIDs with significantly fewer adverse events (27% vs. 63% adverse event rate in one 90-patient trial). 1, 4

Short-term adverse effects to monitor:

• Dysphoria and mood disorders 2, 4
• Elevated blood glucose (particularly important in diabetics—increase monitoring frequency) 2, 4
• Fluid retention 2, 4

Prophylaxis Dosing (Different from Acute Treatment)

For prevention of flares during urate-lowering therapy initiation:

• Low-dose prednisone <10 mg/day is second-line prophylaxis (after colchicine and NSAIDs) 1, 4
• Continue for at least 6 months OR 3 months after achieving target serum urate in patients without tophi 1, 4
• Doses above 10 mg/day for prophylaxis lack consensus and require careful risk-benefit assessment 1

Common Pitfalls to Avoid

• Do not use low prophylactic doses (≤10 mg/day) for acute attacks—these are insufficient for acute inflammation 1
• Do not extend treatment beyond 10-14 days without specific indication, as this increases risk of steroid-related complications 1
• Do not abruptly stop after prolonged use—though for the recommended 5-10 day course, abrupt discontinuation is safe 1