Prednisone Dosing for Pseudogout
For acute pseudogout, start prednisone at 30-35 mg daily for 5 days without taper, or alternatively use 2-5 days at full dose followed by a 7-10 day taper. 1
Recommended Dosing Regimen
The American College of Rheumatology provides Level A evidence supporting oral corticosteroids for crystal arthropathy (which includes pseudogout/CPPD), with the following specific dosing options 1:
- Primary approach: Prednisone 30-35 mg daily for 5 days, then stop abruptly 1
- Alternative approach: Full dose (30-35 mg daily) for 2-5 days, then taper over 7-10 days 1
Both regimens are equally appropriate, though the simpler 5-day course without taper is often preferred for straightforward monoarticular cases 1.
Alternative Routes of Administration
For involvement of 1-2 large joints only, intra-articular corticosteroid injection is the preferred approach rather than oral therapy, with the dose varying based on joint size 1. This route provides targeted therapy with minimal systemic exposure.
For polyarticular involvement or multiple small joints, oral prednisone 30-35 mg daily remains the recommended approach 1.
Clinical Decision Algorithm
Before initiating corticosteroids, assess for absolute contraindications 1:
- Systemic fungal infections (absolute contraindication)
- Uncontrolled diabetes
- Active peptic ulcer disease
- Immunocompromised state
Determine joint involvement pattern:
- 1-2 large joints: Consider intra-articular injection as first choice 1
- Polyarticular or small joints: Use oral prednisone 30-35 mg daily 1
Important Safety Considerations
Short-term corticosteroid courses (5-10 days) carry minimal risk, with adverse effects limited to dysphoria, mood changes, elevated glucose, and fluid retention 1. This makes corticosteroids generally safer and lower cost compared to alternatives like IL-1 inhibitors, establishing them as first-line therapy when NSAIDs are contraindicated 1.
Common Pitfalls to Avoid
Do not confuse acute treatment dosing with prophylactic dosing. Low-dose prednisone for CPPD prophylaxis should be ≤10 mg/day, which is distinctly different from the 30-35 mg used for acute flares 1. Using prophylactic doses to treat acute attacks will result in inadequate symptom control.
Corticosteroids are particularly advantageous in patients with renal impairment, cardiovascular disease, heart failure, or those on anticoagulation, where NSAIDs pose significant risks 2.