What is the role of prednisone (corticosteroid) in treating an acute gout attack in an adult patient, particularly when nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine are contraindicated or ineffective?

Prednisone for Acute Gout

Prednisone is a highly effective first-line treatment for acute gout attacks, particularly when NSAIDs or colchicine are contraindicated, with a recommended dose of 30-35 mg daily for 5 days or 0.5 mg/kg/day for 5-10 days. 1, 2

First-Line Treatment Status

Corticosteroids should be considered as first-line therapy in patients without contraindications because they are generally safer, lower cost, and as effective as NSAIDs with fewer adverse effects. 1 The American College of Rheumatology provides Level A evidence (highest quality) supporting oral corticosteroids as equally effective as NSAIDs for acute gout treatment. 2, 3

• Prednisone is one of three equally effective first-line agents alongside colchicine and NSAIDs, with treatment selection based on patient-specific contraindications and comorbidities. 3, 4
• Direct comparison studies demonstrate rough equivalency between oral corticosteroids and NSAIDs, with significantly fewer adverse events (27% with prednisolone versus 63% with indomethacin). 2

Recommended Dosing Regimens

Two evidence-based dosing strategies exist, both starting at prednisone 0.5 mg/kg per day (approximately 30-35 mg for average adults): 2, 3

Option 1: Fixed Duration Without Taper

• Give full dose (30-35 mg daily) for 5-10 days, then stop abruptly. 2, 3
• This simpler approach is appropriate for straightforward monoarticular cases without significant comorbidities. 2
• The European League Against Rheumatism recommends prednisolone 30-35 mg daily for 5 days as a fixed-dose regimen. 1, 3

Option 2: Short Course Followed by Taper

• Give full dose (30-35 mg daily) for 2-5 days, then taper over 7-10 days before discontinuing. 2, 3
• This tapered approach is recommended for more severe attacks, polyarticular involvement, or patients at higher risk for rebound flares. 2

When Prednisone is the Preferred Choice

Prednisone is particularly preferred over NSAIDs in the following clinical scenarios: 2

• Severe renal impairment (eGFR <30 mL/min): NSAIDs can exacerbate or cause acute kidney injury, and colchicine toxicity is significantly increased in chronic kidney disease. 1, 2, 3
• Cardiovascular disease or heart failure: NSAIDs carry cardiovascular risks that make corticosteroids safer. 1, 3
• Cirrhosis or hepatic impairment: NSAIDs are contraindicated. 1, 4
• Active or recent peptic ulcer disease: NSAIDs risk gastrointestinal bleeding. 2
• Patients on anticoagulation: NSAIDs increase bleeding risk. 2

No dose adjustment is required for renal impairment with corticosteroids, unlike colchicine and NSAIDs. 3

Alternative Routes of Administration

When oral administration is not feasible or for specific joint involvement patterns: 2, 3

• Intra-articular injection: Recommended for involvement of 1-2 large joints, with dose varying by joint size. 2
• Intramuscular triamcinolone acetonide 60 mg: Recommended alternative when patients are NPO or cannot tolerate oral medications, followed by oral prednisone if needed. 2, 3
• Intravenous methylprednisolone: Can be used when IV access is necessary, though IM route is equally effective. 3

Combination Therapy for Severe Attacks

For severe acute gout or polyarticular involvement, initial combination therapy is recommended: 2, 3

• Acceptable combinations include oral corticosteroids plus colchicine, or intra-articular steroids with any other oral modality. 2, 3
• Combination therapy is more effective than monotherapy for particularly severe attacks involving multiple joints. 3

Treatment Timing and Duration

Initiate treatment within 24 hours of acute gout attack onset for optimal efficacy. 2, 4

• Continue treatment at full dose until the gouty attack has completely resolved. 3, 4
• A 5-day course at full dose is typically sufficient for oral corticosteroids. 3

Monitoring and Inadequate Response

Define inadequate response as <20% improvement in pain within 24 hours OR <50% improvement at ≥24 hours after initiating therapy. 2

• For inadequate response, consider adding a second agent rather than increasing corticosteroid dose. 4

Safety Considerations and Contraindications

Assess for absolute contraindications before initiating corticosteroid therapy: 2

• Systemic fungal infections: Absolute contraindication. 1, 3
• Uncontrolled diabetes: Use with caution and monitor blood glucose more frequently. 2, 3
• Active peptic ulcer disease: Relative contraindication. 2
• Immunocompromised state: Requires careful risk-benefit assessment. 2

Short-term adverse effects associated with corticosteroid use include: 1, 2

• Dysphoria and mood disorders
• Elevated blood glucose levels
• Fluid retention
• Immune suppression

These adverse effects are primarily associated with long-term use; short courses (5-10 days) are generally well-tolerated. 1

Role in Prophylaxis During Urate-Lowering Therapy

Low-dose prednisone (<10 mg/day) can be used as a second-line prophylaxis option when colchicine and NSAIDs are not tolerated, contraindicated, or ineffective. 2, 3

• Continue prophylaxis for 3-6 months after initiating urate-lowering therapy. 3, 4
• High daily doses (>10 mg/day) for prophylaxis are inappropriate in most scenarios due to long-term risks. 2, 3

Critical Management Principles

Do not interrupt ongoing urate-lowering therapy during an acute gout attack. 2, 4

• Continuing urate-lowering therapy during acute flares (with appropriate anti-inflammatory coverage) does not significantly prolong flare duration. 3, 4

Common Pitfalls to Avoid

• Failing to start treatment early: Acute gout should be treated as soon as possible; delayed treatment significantly reduces effectiveness. 3, 4
• Using high-dose prednisone (>10 mg/day) for prophylaxis: This carries significant long-term risks and is inappropriate. 2, 3
• Stopping urate-lowering therapy during acute attacks: This outdated practice should be avoided. 2, 4
• Using colchicine without dose adjustment in renal impairment: Colchicine should be avoided entirely in severe CKD (eGFR <30 mL/min) due to fatal toxicity risk. 3
• Prescribing NSAIDs in severe CKD: NSAIDs can cause acute kidney injury and cardiovascular complications. 3