What is the role of intravenous (IV) steroids, such as methylprednisolone, in treating acute gout attacks, particularly in patients with severe symptoms or those who cannot tolerate oral nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine?

Intravenous Corticosteroids for Acute Gout

Intravenous methylprednisolone at 0.5–2.0 mg/kg (approximately 40-140 mg for most adults) is an appropriate and effective treatment for acute gout, particularly when patients cannot take oral medications due to NPO status, surgical conditions, or inability to tolerate oral therapy. 1, 2

When IV Steroids Are Specifically Indicated

IV corticosteroids are the treatment of choice in the following clinical scenarios:

• NPO patients due to surgical or medical conditions where oral access is not feasible 1, 2
• Severe polyarticular gout when rapid systemic treatment is needed and oral route is compromised 2
• Patients with contraindications to NSAIDs and colchicine who cannot take oral medications, including those with:
  • Severe renal impairment (eGFR <30 mL/min) 2, 3
  • Active peptic ulcer disease or recent GI bleeding 1
  • Heart failure or significant cardiovascular disease 4
  • Patients on anticoagulation therapy 1

Dosing and Administration Protocol

The recommended IV methylprednisolone dose is 0.5–2.0 mg/kg as an initial dose, with repeat doses as clinically indicated. 1, 2 This translates to approximately 40-140 mg for average-sized adults. 2

Alternative parenteral options include:

• Intramuscular methylprednisolone at the same dose range (0.5–2.0 mg/kg) 1
• Intramuscular triamcinolone acetonide 60 mg as a single injection 2

The evidence grade for IV/IM methylprednisolone is Level B, while the overall recommendation for glucocorticoids (including parenteral routes) carries high-quality evidence. 1, 2

Comparison to Oral Corticosteroids

When oral intake is possible, oral prednisone at 0.5 mg/kg per day (30-35 mg daily for average adults) for 5-10 days is equally effective and preferred over the parenteral route due to ease of administration. 1, 2 The choice between oral and IV routes should be based purely on the patient's ability to take oral medications, not on severity of the gout attack itself.

Advantages Over Alternative Therapies

IV corticosteroids offer several critical advantages:

• Safer than NSAIDs in patients with renal impairment, cardiovascular disease, heart failure, or GI risk factors 1, 2, 4
• More cost-effective and safer than IL-1 inhibitors (canakinumab, anakinra) for severe gout 1, 2
• No dose adjustment required for renal function, unlike colchicine which carries fatal toxicity risk in renal impairment 2, 3
• Effective when colchicine is contraindicated due to severe renal disease or drug interactions 2

Monitoring Response and Inadequate Response

Define inadequate response as either:

• Less than 20% improvement in pain within 24 hours, OR
• Less than 50% improvement at ≥24 hours after initiating therapy 1, 2

If inadequate response occurs:

• Consider alternative diagnoses (particularly septic arthritis) 1
• Switch to another monotherapy or add a second agent 1
• For severe attacks, consider combination therapy with intra-articular steroids if large joints are involved 2

Critical Safety Considerations and Contraindications

Absolute contraindications to IV corticosteroids:

• Active systemic fungal infections 2, 5
• Current active bacterial infection (relative contraindication requiring careful risk-benefit assessment) 2

Important monitoring points:

• Blood glucose elevation in diabetic patients—monitor closely and adjust diabetic medications proactively 2
• Fluid retention in patients with heart failure—though still safer than NSAIDs 2, 4
• Short-term adverse effects include dysphoria, mood disorders, and immune suppression, though these are primarily concerns with prolonged use 2

Common pitfall to avoid: Short courses (5-10 days) of corticosteroids pose minimal bone density risk and should not be avoided in patients with osteoporosis. 2

Clinical Algorithm for IV Steroid Use

1. Assess oral intake capability: If patient is NPO or cannot tolerate oral medications, proceed with IV route 1, 2
2. Check for absolute contraindications: Active systemic fungal infection 2, 5
3. Evaluate joint involvement:
   • If 1-2 large accessible joints: Consider intra-articular injection as alternative to IV 1, 2
   • If polyarticular or inaccessible joints: Proceed with IV methylprednisolone 2
4. Administer IV methylprednisolone 0.5–2.0 mg/kg (typically 40-140 mg) 1, 2
5. Repeat doses as clinically indicated based on response 1
6. Transition to oral therapy once patient can tolerate oral intake 2

Long-Term Management Considerations

Do not interrupt ongoing urate-lowering therapy during the acute attack. 2, 3 Once the acute flare resolves and oral intake is restored, ensure the patient is on appropriate urate-lowering therapy (allopurinol or febuxostat) to prevent future attacks. 3

For prophylaxis during urate-lowering therapy initiation: Low-dose prednisone (<10 mg/day) can be used for 3-6 months if colchicine and NSAIDs are contraindicated, but avoid high-dose prednisone (>10 mg/day) for prophylaxis. 2