What is the recommended dose of prednisone (corticosteroid) for treating a gout flare?

Prednisone Dosing for Acute Gout Flare

For treating an acute gout flare, use prednisone 30-35 mg daily for 5 days, or alternatively 0.5 mg/kg/day for 5-10 days at full dose then stop abruptly. 1, 2

Recommended Dosing Regimens

The American College of Rheumatology endorses two evidence-based approaches for oral prednisone:

• Fixed-dose regimen: 30-35 mg daily for 5 days (simplest and most practical for most patients) 1, 2
• Weight-based regimen: 0.5 mg/kg/day for 5-10 days at full dose, then stop without taper 1, 2
• Alternative weight-based regimen with taper: 0.5 mg/kg/day for 2-5 days at full dose, then taper over 7-10 days 1, 2

The fixed-dose regimen of 30-35 mg daily for 5 days is equally effective to weight-based dosing and represents the most straightforward approach for clinical practice. 1 This dosing has Level A evidence supporting its efficacy, equivalent to NSAIDs but with fewer adverse effects. 2

When Prednisone is the Preferred First-Line Choice

Prednisone should be prioritized over other first-line options (colchicine, NSAIDs) in specific clinical scenarios:

• Severe renal impairment (GFR <30 mL/min): Corticosteroids are the safest option as colchicine and NSAIDs should be avoided 1, 3
• Cardiovascular disease: Oral corticosteroids are safer than NSAIDs due to cardiovascular risks associated with NSAIDs 1
• Heart failure, cirrhosis, or peptic ulcer disease: Prednisone avoids gastrointestinal and fluid retention risks of NSAIDs 3
• Patients on anticoagulation: Corticosteroids avoid bleeding risk amplification from NSAIDs 3

Alternative Routes When Oral Administration is Not Possible

For patients unable to take oral medications (NPO, nausea/vomiting, surgical status):

• Intramuscular triamcinolone acetonide 60 mg as a single injection is the specifically recommended IM dose 2
• Intramuscular methylprednisolone 40-140 mg (0.5-2.0 mg/kg) is an alternative IM option 2
• Intra-articular corticosteroid injection for involvement of 1-2 large accessible joints (dose varies by joint size) 2

The American College of Rheumatology strongly recommends parenteral glucocorticoids over IL-1 inhibitors or ACTH when oral medications cannot be taken, citing safety and cost advantages. 4, 2

Treatment Duration and Monitoring

• Continue treatment until the gout attack has completely resolved 1
• A 5-day course at full dose is typically sufficient for most acute flares 1
• No taper is necessary after 5 days of treatment at standard doses 1, 2

Combination Therapy for Severe Attacks

For particularly severe acute gout with multiple joint involvement:

• Combination therapy with oral corticosteroids plus colchicine is more effective than monotherapy 1, 3
• Other acceptable combinations include intra-articular steroids with any other modality, or colchicine with NSAIDs 1

Critical Safety Considerations and Monitoring

Monitor for short-term adverse effects during corticosteroid therapy:

• Blood glucose elevation: Monitor glucose levels more frequently, especially in diabetic patients 2, 3
• Mood changes and dysphoria: Counsel patients about potential mood disorders 2, 3
• Fluid retention: Watch for edema, particularly in patients with heart failure 2, 3
• Immune suppression: Consider infection risk with prolonged use 3

Absolute contraindication: Systemic fungal infections 2, 3

Common Pitfalls to Avoid

• Do not discontinue urate-lowering therapy during the flare: Continue allopurinol or febuxostat if already prescribed 3
• Do not use high-dose prednisone (>10 mg/day) for flare prophylaxis: This is inappropriate; prophylactic dosing should be <10 mg/day 2
• Do not delay treatment: Early intervention is crucial for optimal effectiveness 1
• Do not use colchicine with severe renal impairment or strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporine) as alternatives to prednisone 3

Role in Flare Prophylaxis During Urate-Lowering Therapy Initiation

Low-dose prednisone (<10 mg/day) serves as a second-line prophylaxis option when colchicine and NSAIDs are contraindicated, not tolerated, or ineffective during initiation of urate-lowering therapy. 1, 2 Prophylaxis should continue for 3-6 months after starting urate-lowering therapy. 1