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

Acute Gout Prednisone Dosing

For acute gout, start prednisone at 0.5 mg/kg per day (approximately 30-35 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 7-10 day taper. 1

Standard Oral Prednisone Regimens

The American College of Rheumatology provides two evidence-based dosing options:

• Primary regimen: Prednisone 0.5 mg/kg per day for 5-10 days at full dose, then discontinue (Evidence Level A) 1
• Alternative regimen: Prednisone 0.5 mg/kg per day for 2-5 days at full dose, then taper over 7-10 days before discontinuing (Evidence Level C) 1
• Methylprednisolone dose pack: An appropriate option based on provider and patient preference (Evidence Level C) 1, 2

The European League Against Rheumatism recommends a fixed dose of prednisolone 30-35 mg daily for 5 days, which aligns with the weight-based dosing for average-sized adults. 2, 3

When to Choose Corticosteroids Over Alternatives

Corticosteroids should be considered first-line therapy in patients without contraindications because they are equally effective as NSAIDs with fewer adverse effects, particularly gastrointestinal toxicity, and are lower cost. 2, 3

Specific scenarios favoring corticosteroids include:

• Patients with renal impairment, heart failure, peptic ulcer disease, or on anticoagulation (NSAID contraindications) 2, 3
• Polyarticular involvement or multiple large joints affected 1
• Severe acute gout attacks (≥7/10 on pain scale) 1

Alternative Corticosteroid Routes

For patients unable to take oral medications or requiring rapid intervention:

• Intramuscular triamcinolone acetonide: 60 mg as a single dose, followed by oral prednisone as above (Evidence Level C) 1, 2
• Intra-articular injection: For 1-2 large joints, dose varies by joint size; can be combined with oral therapy (Evidence Level B) 1, 3

Note that intramuscular triamcinolone acetonide as monotherapy did not reach consensus recommendation by the American College of Rheumatology. 1

Combination Therapy for Severe Attacks

For severe acute gout with polyarticular involvement or pain ≥7/10:

• Combine oral corticosteroids with colchicine at prophylactic dosing (Evidence Level C) 1, 2
• Combine intra-articular steroids with any other oral modality (Evidence Level C) 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Treatment Duration and Monitoring

• Continue treatment at full dose until the gout attack completely resolves 1, 3
• Define inadequate response as <20% pain improvement within 24 hours or <50% improvement at ≥24 hours 1
• If inadequate response occurs, switch to another monotherapy or add a second agent 1

Important Safety Considerations

Contraindications to assess before initiating corticosteroids include:

• Systemic fungal infections 2, 3
• Uncontrolled diabetes (monitor glucose more frequently during therapy) 2, 3
• Active peptic ulcer disease 2
• Immunocompromised state 2

Common adverse effects with short-term use include dysphoria, mood disorders, elevated blood glucose, and fluid retention. 2, 3

Prophylaxis Dosing (Different from Acute Treatment)

For prophylaxis during urate-lowering therapy initiation, use low-dose prednisone <10 mg/day as a second-line option only if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective. 1, 2, 3 Do not use high doses (>10 mg/day) for prophylaxis. 2