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

Prednisone Dosing for Acute Gout

For acute gout, start prednisone at 0.5 mg/kg per day (approximately 30-35 mg daily for most adults) for either 5-10 days at full dose then stop abruptly, or give 2-5 days at full dose followed by a 7-10 day taper. 1, 2

Standard Dosing Regimens

The American College of Rheumatology provides two equally acceptable approaches 1:

• Simple regimen: Prednisone 0.5 mg/kg per day (30-35 mg for average adults) for 5-10 days at full dose, then stop abruptly 1, 2
• Tapered regimen: Prednisone 0.5 mg/kg per day for 2-5 days at full dose, followed by tapering over 7-10 days before discontinuation 1, 2

The European League Against Rheumatism recommends a fixed-dose approach of prednisolone 30-35 mg daily for 5 days, which is simpler and equally effective 1, 2

When to Choose Each Approach

Use the simple 5-10 day course without taper for 1:

• Straightforward monoarticular gout with no significant comorbidities 1
• Patients at lower risk for rebound flares 1

Use the tapered approach (2-5 days full dose, then 7-10 day taper) for 1:

• More severe attacks with polyarticular involvement 1
• Patients at higher risk for rebound flares, including those with renal impairment 1
• Patients with multiple comorbidities 1

Why Corticosteroids Are First-Line

The American College of Physicians emphasizes that corticosteroids should be considered first-line therapy in patients without contraindications because they are 1, 2:

• Generally safer and lower cost compared to colchicine 1, 2
• As effective as NSAIDs with fewer adverse effects (27% adverse events vs 63% with indomethacin) 1
• Particularly preferred in patients with severe renal impairment, cardiovascular disease, heart failure, cirrhosis, peptic ulcer disease, or those on anticoagulation 1, 2

Alternative Routes When Oral Not Feasible

For patients unable to take oral medications 1:

• Intramuscular triamcinolone acetonide 60 mg as a single injection 1
• Intramuscular methylprednisolone 40-140 mg (0.5-2.0 mg/kg) 1
• Intra-articular corticosteroid injection for involvement of 1-2 large joints 1, 2

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement, consider initial combination therapy 1, 2:

• Oral corticosteroids plus colchicine 1, 2
• Intra-articular steroids with any other oral modality 1

Critical Timing Considerations

• Initiate treatment within 24 hours of acute gout attack onset for optimal efficacy 1
• Colchicine is most effective within 12-36 hours of symptom onset; beyond this window, prednisolone becomes the preferred choice 3

Absolute Contraindications

Corticosteroids are absolutely contraindicated in 1, 2:

• Systemic fungal infections 1, 2

Relative contraindications requiring careful monitoring 1:

• Uncontrolled diabetes (monitor blood glucose closely) 1, 2
• Active peptic ulcer disease 1
• Immunocompromised state 1

Common Pitfalls to Avoid

• Do NOT interrupt ongoing urate-lowering therapy during an acute gout attack 1
• Do NOT use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation 1, 2
• Do NOT use standard-dose colchicine without significant dose reduction in renal impairment (GFR <30 mL/min)—the risk of toxicity outweighs benefits 1
• Do NOT use NSAIDs in severe CKD due to risk of acute kidney injury 1, 2

Monitoring for Adverse Effects

Short-term corticosteroid use may cause 1, 2:

• Dysphoria and mood disorders 1, 2
• Elevated blood glucose levels (monitor more frequently in diabetics) 1, 2
• Fluid retention 1, 2
• Immune suppression 1

Prophylaxis During Urate-Lowering Therapy

If initiating urate-lowering therapy after the acute flare resolves, low-dose prednisone (<10 mg/day) can be used as second-line prophylaxis for 3-6 months if colchicine and NSAIDs are contraindicated 1, 2