What is the role of oral corticosteroids (oral steroids) in the treatment of gout?

From the Guidelines

Oral steroids are a recommended first-line treatment for acute gout, particularly for patients without contraindications, due to their effectiveness and relatively low cost. According to the American College of Physicians guideline 1, high-quality evidence supports the use of corticosteroids, NSAIDs, and colchicine to reduce pain in patients with acute gout. Some key points to consider when prescribing oral steroids for gout include:

• Prednisolone at a dose of 35 mg for 5 days has been shown to be effective in treating acute gout 1
• Corticosteroids are generally safer and have fewer adverse effects compared to NSAIDs, making them a preferred option for patients without contraindications 1
• Potential adverse effects of oral steroids include dysphoria, mood disorders, elevation of blood glucose levels, immune suppression, and fluid retention, which should be monitored and managed accordingly 1
• Contraindications for corticosteroids include systemic fungal infections or known contraindications, and caution should be exercised when prescribing to patients with certain medical conditions 1 When prescribing oral steroids for gout, it is essential to weigh the benefits and risks, consider alternative treatment options, and closely monitor patients for potential adverse effects.

From the Research

Oral Steroids for Gout

• Oral steroids, such as prednisolone, are effective therapies for the treatment of acute gout 2, 3, 4, 5.
• Systemic corticosteroids have similar efficacy to therapeutic doses of NSAIDs, with studies supporting oral and intramuscular use 5.
• A pragmatic, prospective, double-blind, double-dummy, parallel-group, randomized, non-inferiority trial compared prednisolone with colchicine in terms of non-inferiority in patients with acute gout, with the intervention group receiving 30 mg prednisolone for 5 days 2, 4.
• The primary outcome was the absolute level of pain on day 3, measured on a numerical rating scale, with prednisolone considered non-inferior if the effect estimate including the confidence intervals was lower than a margin of 1 unit on the NRS 2, 4.
• Secondary outcomes included average response to treatment, joint swelling and tenderness, physical function of the joint, and patients' global assessment of treatment success 2, 4.
• The use of oral steroids for gout is supported by evidence, but the choice of treatment should be guided by comorbidities and potential side effects 3, 5.

Comparison with Other Treatments

• Colchicine is another effective treatment for acute gout, with low-dose colchicine demonstrating a comparable tolerability profile to placebo and a significantly lower side effect profile to high-dose colchicine 5, 6.
• A systematic review found that NSAIDs, COX-2 inhibitors, corticosteroids, colchicine, ACTH, and canakinumab have evidence to suggest efficacy in the treatment of acute gout 5.
• A Cochrane review found low-quality evidence that low-dose colchicine may be an effective treatment for acute gout when compared to placebo, and low-quality evidence that its benefits may be similar to NSAIDs 6.

Safety and Efficacy

• The safety and efficacy of oral steroids for gout have been evaluated in several studies, with evidence suggesting that they are effective in reducing pain and inflammation 2, 4, 5.
• However, the use of oral steroids should be guided by potential side effects, such as increased risk of adverse events, and comorbidities 3, 5, 6.