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

Prednisone Dosing for Acute Gout Flare

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

Primary Dosing Regimens

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

• Fixed-dose regimen: Prednisone 30-35 mg daily for 5 days is the simplest and most practical option for most patients, supported by Level A evidence 1, 2
• Weight-based regimen: Prednisone 0.5 mg/kg/day for 5-10 days at full dose then stop abruptly 1, 2
• Tapered regimen: Prednisone 0.5 mg/kg/day for 2-5 days at full dose, followed by a 7-10 day taper 1, 2

Choosing Between Regimens

For straightforward monoarticular gout with no significant comorbidities, use the simpler 5-10 day course without taper 2. This approach minimizes complexity and is equally effective for uncomplicated cases.

For severe attacks, polyarticular involvement, or patients at higher risk for rebound flares, use the tapered approach (2-5 days full dose, then 7-10 day taper) 2. This includes patients with renal impairment or more aggressive disease.

When Prednisone is the Preferred First-Line Choice

Prednisone is explicitly preferred over NSAIDs and colchicine in specific clinical scenarios:

• Severe renal impairment (eGFR <30 mL/min): Prednisone requires no dose adjustment and is the safest option, as NSAIDs can cause acute kidney injury and colchicine carries fatal toxicity risk 1, 2
• Cardiovascular disease or heart failure: NSAIDs carry unacceptable cardiovascular risks 1, 2
• Peptic ulcer disease or GI bleeding history: Corticosteroids have fewer gastrointestinal adverse effects than NSAIDs 1, 2
• Patients on anticoagulation: NSAIDs increase bleeding risk 1
• Cirrhosis or hepatic impairment: NSAIDs are contraindicated 1

Alternative Routes of Administration

• Intra-articular injection: For involvement of 1-2 large joints, intra-articular corticosteroid injection is equally effective and avoids systemic effects 1, 2
• Intramuscular triamcinolone acetonide 60 mg: Recommended when patients are NPO, cannot tolerate oral medications, or require rapid relief 1, 2
• Intramuscular methylprednisolone 40-140 mg: Alternative IM option with similar efficacy 1

Combination Therapy for Severe Attacks

For severe acute gout with multiple joint involvement, initial combination therapy is more effective than monotherapy 1, 2:

• Oral corticosteroids plus colchicine 1, 2
• Intra-articular steroids with any other oral modality 1, 2
• Colchicine plus NSAIDs (if no contraindications) 1

Treatment Timing and Monitoring

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

Absolute Contraindications to Prednisone

• Systemic fungal infections: This is an absolute contraindication 1, 2
• Current active infection: Corticosteroids cause immune suppression and can worsen infections 1

Important Safety Considerations

Short-term corticosteroid use (5-10 days) is associated with:

• Dysphoria and mood disorders 1, 2
• Elevated blood glucose levels (monitor closely in diabetic patients) 1, 2
• Fluid retention 1, 2
• Minimal bone density risk with short courses 1

Critical Pitfalls to Avoid

• Do not interrupt ongoing urate-lowering therapy during an acute flare 2
• 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 use colchicine in severe renal impairment (eGFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin), as fatal toxicity can occur 1
• Do not use NSAIDs in severe CKD due to risk of acute kidney injury 1

Prophylaxis During Urate-Lowering Therapy

When 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 not tolerated, contraindicated, or ineffective 1, 2. This is distinct from acute flare treatment and uses much lower doses.