What is the recommended dose of prednisolone (corticosteroid) for an adult patient with an acute flare of gout and no contraindications?

Prednisolone Dosing for Acute Gout Flare

For an adult patient with an acute gout flare and no contraindications, start prednisolone at 30-35 mg daily for 5 days, then stop abruptly—this is the simplest and most effective regimen supported by both the American College of Rheumatology and European League Against Rheumatism. 1, 2

Standard Dosing Regimens

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

• Fixed-dose regimen (preferred for simplicity): Prednisolone 30-35 mg daily for 5-10 days at full dose, then stop abruptly 1, 2
• Tapered regimen (for severe attacks): Prednisolone 0.5 mg/kg per day (approximately 30-35 mg for average adults) for 2-5 days at full dose, followed by tapering over 7-10 days 1, 2

The European League Against Rheumatism specifically recommends prednisolone 30-35 mg/day for 3-5 days as first-line therapy 1, 2

When to Choose Each Approach

Use the simple 5-day course without taper for:

• Monoarticular involvement with no significant comorbidities 1
• Straightforward cases in otherwise healthy patients 1

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

• Severe attacks with polyarticular involvement 1
• Patients at higher risk for rebound flares 1
• More severe attacks requiring extended anti-inflammatory coverage 1

Alternative Routes When Oral Route Not Feasible

• Intramuscular triamcinolone acetonide 60 mg as a single injection when patients cannot take oral medications 1
• Intra-articular corticosteroid injection for involvement of 1-2 large joints (dose varies by joint size) 1, 2

Critical Timing and Monitoring

• Initiate treatment within 24 hours of acute gout attack onset for optimal efficacy 1
• Define inadequate response as <20% improvement in pain within 24 hours OR <50% improvement at ≥24 hours 1
• For inadequate response, consider combination therapy with colchicine plus oral corticosteroids 1

When Corticosteroids Are the Preferred Choice

Corticosteroids should be first-line therapy in patients with: 1, 2

• Severe renal impairment (eGFR <30 mL/min)—colchicine and NSAIDs must be avoided 1, 2
• Cardiovascular disease, heart failure, or cirrhosis—NSAIDs carry significant risks 1, 2
• Active peptic ulcer disease—NSAIDs contraindicated 1
• Patients on anticoagulation—NSAIDs increase bleeding risk 1

Important Safety Considerations

Absolute contraindications to corticosteroids: 1, 2

• Systemic fungal infections
• Uncontrolled diabetes (relative—requires close glucose monitoring)

Monitor for short-term adverse effects: 1, 2

• Dysphoria and mood disorders
• Elevated blood glucose levels (check more frequently in diabetics)
• Fluid retention
• Immune suppression

Common Pitfalls to Avoid

• Do not interrupt ongoing urate-lowering therapy during an acute flare—continue it with appropriate anti-inflammatory coverage 1
• Do not use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation—this is inappropriate and carries long-term risks 1, 2
• Do not combine NSAIDs with systemic corticosteroids—synergistic gastrointestinal toxicity is a concern 3

Combination Therapy for Severe Attacks

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

• Oral corticosteroids plus colchicine
• Intra-articular steroids with any other oral modality
• These combinations are more effective than monotherapy for severe attacks 1, 2

Evidence Quality

The American College of Rheumatology provides Level A evidence (highest quality) supporting oral corticosteroids as equally effective as NSAIDs for acute gout treatment, with fewer adverse effects 1, 2. Corticosteroids are safer and lower cost compared to IL-1 inhibitors, making them an excellent first-line choice 1.