What is the recommended dose of prednisone (corticosteroid) for an adult patient experiencing a gouty flare?

Prednisone Dosing for Acute Gouty Flare

For an acute gout flare, use prednisone 30-35 mg daily for 5 days without a taper, or alternatively 0.5 mg/kg/day (approximately 30-35 mg for most adults) for 2-5 days at full dose followed by a 7-10 day taper. 1, 2, 3

Primary Dosing Regimens

The American College of Rheumatology provides two evidence-based approaches 1, 2:

• Fixed-dose regimen: Prednisone 30-35 mg daily for 5 days, then stop abruptly 1, 2
• Weight-based regimen with taper: Prednisone 0.5 mg/kg/day for 2-5 days at full dose, then taper over 7-10 days 1, 2, 3

Both regimens carry Level A evidence (highest quality) for efficacy in treating acute gout 2.

Choosing Between Regimens

Use the simpler 5-day course without taper for:

• Monoarticular involvement 2
• Straightforward cases without significant comorbidities 2
• Patients with good treatment adherence 1

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

• Severe attacks or polyarticular involvement 2
• Patients at higher risk for rebound flares 2
• More complex presentations 2

Alternative Routes When Oral Route Not Feasible

• Intramuscular: Triamcinolone acetonide 60 mg IM as a single injection 1, 2
• Intra-articular: For 1-2 large joints involved, inject directly into affected joint(s) 1, 2

Why Prednisone is First-Line

Corticosteroids are recommended as first-line therapy because they are 1, 2:

• As effective as NSAIDs with fewer adverse effects 1, 2
• Generally safer and lower cost compared to colchicine 1, 2
• The safest option in patients with severe renal impairment (eGFR <30 mL/min) 1, 2
• Preferred over NSAIDs in patients with cardiovascular disease, heart failure, cirrhosis, or peptic ulcer disease 1, 2

Combination Therapy for Severe Attacks

For severe acute gout with multiple joint involvement, consider initial combination therapy 1, 2:

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

Treatment Timing and Monitoring

• Initiate treatment within 24 hours of symptom onset for optimal efficacy 2
• Continue treatment until the gouty attack has completely resolved 1
• Inadequate response is defined as <20% improvement in pain within 24 hours or <50% improvement at ≥24 hours 2

Important Safety Considerations

Absolute contraindications 1, 2:

• Systemic fungal infections 1, 2
• Current active infection 2

Short-term adverse effects to monitor 1, 2:

• Dysphoria and mood disorders 1, 2
• Elevated blood glucose levels (monitor closely in diabetics) 1, 2
• Fluid retention 1, 2

Common Pitfalls to Avoid

• Do not use high-dose prednisone (>10 mg/day) for prophylaxis during urate-lowering therapy initiation—this is inappropriate and carries significant long-term risks 1, 2
• Do not interrupt ongoing urate-lowering therapy during an acute gout attack 2
• Do not prolong treatment with high-dose oral corticosteroids beyond recommended duration, as this has diminishing chance of achieving remission and increasing risk of complications 4

Prophylaxis During Urate-Lowering Therapy

If initiating urate-lowering therapy after the acute flare resolves, use low-dose prednisone (<10 mg/day) as a second-line prophylaxis option for 3-6 months if colchicine and NSAIDs are contraindicated 1, 3, 5, 6.