What is the efficacy of prednisone (corticosteroid) versus colchicine for treating acute gout?

Prednisone vs Colchicine for Acute Gout

Both prednisone and colchicine are equally effective for treating acute gout, but prednisone should be considered first-line therapy in patients without contraindications because it is safer, lower cost, and has fewer adverse effects. 1

Evidence for Equivalent Efficacy

• High-quality evidence demonstrates that corticosteroids, NSAIDs, and colchicine are all effective treatments to reduce pain in patients with acute gout, with no significant difference in efficacy between these options. 1
• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) achieves treatment success (≥50% pain reduction at 32-36 hours) in approximately 42% of patients compared to 17% with placebo (absolute improvement of 25%). 2
• Oral prednisone at 35 mg for 5 days has been successfully used to treat acute gout with Level A evidence supporting its equivalency to NSAIDs. 1, 3

Why Prednisone is Preferred First-Line

• Prednisone offers superior safety profile: Direct comparison studies show only 27% of prednisolone patients experience adverse events compared to 63% in the indomethacin group. 3
• Cost advantage: Corticosteroids are a low-cost treatment option compared to colchicine, which remains more expensive even in generic formulation. 1
• Broader applicability: Prednisone can be safely used in patients with renal impairment, whereas colchicine is contraindicated in severe renal impairment (GFR <30 mL/min). 1, 2

Recommended Dosing Regimens

Prednisone Dosing

• Start with 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 5-10 days at full dose and then stopped, or alternatively given for 2-5 days at full dose followed by tapering for 7-10 days. 3
• The European League Against Rheumatism recommends prednisolone 30-35 mg daily for 3-5 days as first-line treatment. 2, 3

Colchicine Dosing (When Used)

• Administer 1.2 mg at first sign of flare followed by 0.6 mg one hour later (total 1.8 mg over one hour), then continue 0.6 mg once or twice daily until attack resolves. 2
• This low-dose regimen is as effective as high-dose colchicine (4.8 mg over 6 hours) but with significantly fewer gastrointestinal side effects (number needed to treat = 5 for 50% pain reduction). 2

Critical Safety Considerations

Prednisone Contraindications

• Systemic fungal infections (absolute contraindication). 1, 3
• Short-term adverse effects include dysphoria, mood disorders, elevated blood glucose levels, immune suppression, and fluid retention. 1, 3

Colchicine Contraindications

• Severe renal impairment (GFR <30 mL/min). 2
• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin) or P-glycoprotein inhibitors (cyclosporine) is an absolute contraindication. 2
• All participants treated with high-dose colchicine in trials experienced gastrointestinal side effects (diarrhea and/or vomiting), with number needed to harm = 1. 4

Clinical Decision Algorithm

Step 1: Assess Contraindications

• If no contraindications to corticosteroids: Use prednisone 30-35 mg daily for 5 days. 1, 3
• If corticosteroids contraindicated but colchicine safe: Use low-dose colchicine regimen (1.2 mg then 0.6 mg one hour later). 2

Step 2: Consider Patient-Specific Factors

• Renal disease, heart failure, or cirrhosis: Strongly favor prednisone over colchicine or NSAIDs. 1, 3
• Patients on CYP3A4 or P-glycoprotein inhibitors: Avoid colchicine entirely; use prednisone. 2
• Uncontrolled diabetes or active infection: Avoid prednisone; consider colchicine if renal function adequate. 3

Step 3: Timing Considerations

• Colchicine is only effective when initiated within 36 hours of symptom onset; beyond this window, prednisone remains effective. 2
• For maximum colchicine efficacy, treatment should ideally begin within 12 hours of symptom onset. 2

Common Pitfalls to Avoid

• Do not use high-dose colchicine regimens: The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients with no additional benefit. 2, 5
• Do not delay treatment: Colchicine effectiveness drops significantly after 36 hours from symptom onset. 2
• Do not combine NSAIDs with corticosteroids: There are concerns about synergistic gastrointestinal toxicity. 2
• Do not use colchicine in patients with both renal/hepatic impairment AND taking CYP3A4/P-glycoprotein inhibitors: This combination has resulted in deaths. 2, 5

Severe or Polyarticular Attacks

• For severe attacks involving multiple large joints, consider combination therapy with colchicine and prednisone for synergistic anti-inflammatory effects targeting different pathways. 2
• Intramuscular triamcinolone acetonide 60 mg is an alternative when oral route is not feasible. 3