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

Efficacy of Prednisone versus Colchicine for Acute Gout

Prednisone and colchicine are equally effective for treating acute gout, but prednisone should be considered first-line therapy because it is safer, lower cost, and has fewer adverse effects. 1

Evidence for Equivalent Efficacy

High-quality evidence demonstrates no significant difference in pain reduction between corticosteroids and colchicine for acute gout treatment. 1 Both agents effectively reduce pain and clinical symptoms, with low-dose colchicine achieving treatment success in approximately 42% of patients compared to 17% with placebo (absolute improvement of 25%). 1 The American College of Rheumatology provides Level A evidence (highest quality) supporting oral corticosteroids as equally effective treatment options. 2

Recommended First-Line Choice: Prednisone

The American College of Physicians recommends prednisone as first-line therapy in patients without contraindications due to superior safety profile and lower cost. 1 The recommended dosing is:

• Prednisone 30-35 mg daily for 5 days (no taper needed for short course) 1, 2
• Alternative: 0.5 mg/kg per day for 5-10 days at full dose then stop, or taper over 7-10 days 3, 2
• Methylprednisolone dose pack is also acceptable 3, 2

When to Choose Colchicine Instead

Use colchicine when prednisone is contraindicated: 1

• Systemic fungal infections (absolute contraindication to prednisone) 1
• Uncontrolled diabetes 2
• Active peptic ulcer disease 2
• Immunocompromised state 2

Colchicine dosing: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later, then 0.6 mg once or twice daily until attack resolves. 1 This low-dose regimen is as effective as high-dose colchicine but with significantly fewer gastrointestinal side effects. 4

Critical Safety Considerations

Prednisone is strongly favored over colchicine in patients with: 1

• Renal disease (colchicine contraindicated if GFR <30 mL/min) 1, 4
• Heart failure 1
• Cirrhosis 1

Colchicine absolute contraindications: 1, 4

• Severe renal impairment (GFR <30 mL/min) 1, 4
• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin) 1, 4
• Concurrent use of P-glycoprotein inhibitors (cyclosporine) 1, 4

Adverse Effect Profiles

Prednisone short-term adverse effects: 2

• Dysphoria and mood disorders 2
• Elevated blood glucose 2
• Fluid retention 2

Colchicine adverse effects: 5

• Gastrointestinal side effects (diarrhea, vomiting) occur in nearly all patients with older high-dose regimens 5
• Low-dose regimen has significantly better tolerability 4
• Number needed to harm with colchicine versus placebo is 1 5

Alternative Routes for Prednisone

When oral administration is not possible: 2

• Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone 3, 2
• Intra-articular injection for involvement of 1-2 large joints (dose varies by joint size) 3, 2

Severe or Polyarticular Attacks

For severe attacks involving multiple large joints, consider combination therapy with both colchicine and prednisone for synergistic anti-inflammatory effects. 3, 1, 4 This approach is particularly appropriate for polyarticular arthritis. 3, 4

Critical Timing Consideration

Colchicine is only effective when initiated within 36 hours of symptom onset. 4 The most important determinant of therapeutic success with either agent is early initiation of treatment at appropriate doses. 6