What is the recommended dose of prednisone (corticosteroid) for 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

Recommended Dosing Regimens

The American College of Rheumatology provides two evidence-based approaches 1:

Option 1: Short course without taper

• Prednisone 0.5 mg/kg per day (30-35 mg for average adults) for 5-10 days at full dose, then stop abruptly 1
• Best for straightforward monoarticular gout without significant comorbidities 1

Option 2: Tapered regimen

• Prednisone 0.5 mg/kg per day (30-35 mg) for 2-5 days at full dose, followed by tapering over 7-10 days before discontinuation 1
• Preferred for severe attacks, polyarticular involvement, or patients at higher risk for rebound flares 1

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

When to Choose Corticosteroids as First-Line

Corticosteroids should be your first choice in these clinical scenarios:

• Renal impairment: Corticosteroids are the safest option when GFR <30 mL/min, as NSAIDs can cause acute kidney injury and colchicine toxicity is significantly increased 1, 2
• Cardiovascular disease: Safer than NSAIDs due to cardiovascular risks associated with NSAIDs 2
• Gastrointestinal disease: Fewer GI adverse effects compared to NSAIDs (27% vs 63% adverse events) 1
• Anticoagulation therapy: Corticosteroids avoid bleeding risk associated with NSAIDs 1
• Late presentation: When patient presents >36 hours after symptom onset, as colchicine efficacy drops significantly beyond this window 3

The American College of Rheumatology provides Level A evidence (highest quality) supporting oral corticosteroids as equally effective as NSAIDs with fewer adverse effects 1

Alternative Routes of Administration

For patients unable to take oral medications:

• Intramuscular triamcinolone acetonide 60 mg as a single injection 1
• This is particularly indicated when patient is NPO due to surgical/medical conditions 1

For monoarticular or oligoarticular involvement (1-2 large joints):

• Intra-articular corticosteroid injection is an appropriate alternative, with dose based on joint size 4, 1
• Can be combined with oral therapy for severe attacks 1

Combination Therapy for Severe Attacks

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

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

The American College of Rheumatology supports combination therapy for attacks not responding adequately to monotherapy (defined as <20% improvement in pain within 24 hours or <50% improvement at ≥24 hours) 1

Critical Safety Considerations and Contraindications

Absolute contraindication:

• Systemic fungal infections 1

Monitor closely for short-term adverse effects:

• Dysphoria and mood disorders 1
• Elevated blood glucose (particularly in diabetics) 1, 2
• Fluid retention 1
• Immune suppression 2

Common pitfalls to avoid:

• Do NOT use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation 1
• Do NOT interrupt ongoing urate-lowering therapy during an acute attack 1
• Do NOT delay treatment—initiate within 24 hours of symptom onset for optimal efficacy 1

Prophylaxis During Urate-Lowering Therapy

If initiating urate-lowering therapy, low-dose prednisone (<10 mg/day) can be used as second-line prophylaxis for 3-6 months when colchicine and NSAIDs are contraindicated, not tolerated, or ineffective 1, 2

Practical Algorithm Summary

1. Confirm diagnosis and assess timing of presentation 1
2. Evaluate contraindications to corticosteroids (fungal infection, uncontrolled diabetes) 1
3. Assess joint involvement: 1-2 large joints vs polyarticular 1
4. Choose route: Oral preferred; IM if NPO; intra-articular for 1-2 large joints 1
5. Select regimen: 30-35 mg daily for 5 days (simple) vs tapered approach for severe/polyarticular disease 1, 2
6. Monitor response at 24 hours; consider combination therapy if inadequate response 1
7. Continue treatment until attack completely resolves 4, 2