What is the recommended tapering regimen for IV (intravenous) hydrocortisone in an adult patient with acute gout and no significant underlying health issues?

IV Hydrocortisone Tapering for Acute Gout

For acute gout treated with IV hydrocortisone, taper when vasopressors are no longer required or when the patient can transition to oral therapy; typically give 2-5 days at full dose followed by a 7-10 day taper, or simply stop after 5-10 days if the attack has fully resolved. 1, 2

Initial IV Hydrocortisone Dosing

• Start with IV hydrocortisone 50 mg three times daily (150 mg total daily) for patients requiring parenteral therapy due to NPO status, surgical conditions, or inability to tolerate oral medications 1, 2
• Alternative IV dosing: methylprednisolone 0.5-2.0 mg/kg (approximately 40-140 mg for most adults) can be used instead of hydrocortisone 2
• IV corticosteroids are particularly indicated when oral access is not feasible or in patients with active peptic ulcer disease, recent GI bleeding, or those on anticoagulation 2

Transition Strategy from IV to Oral

The most critical decision point is determining when to switch from IV to oral corticosteroids, which should occur as soon as the patient can tolerate oral intake. 1, 2

• Transition to oral prednisone 30-35 mg daily (equivalent to 0.5 mg/kg/day) once oral intake is established 1, 2
• The switch from IV to oral can typically occur within 24-48 hours if the patient's clinical status allows 2
• Continue monitoring for adequate response, defined as ≥20% improvement in pain within 24 hours or ≥50% improvement at 24 hours after initiating therapy 2

Tapering Regimens

Option 1: Abrupt Discontinuation (for straightforward cases)

• Give full-dose oral prednisone 30-35 mg daily for 5-10 days, then stop abruptly 1, 2
• This approach is appropriate for monoarticular involvement with no significant comorbidities and good initial response 2

Option 2: Gradual Taper (preferred for most patients)

• Give full dose (30-35 mg daily) for 2-5 days, then taper over 7-10 days before discontinuing 1, 2
• This tapered approach is recommended for severe attacks, polyarticular involvement, or patients at higher risk for rebound flares 2
• Example taper schedule: 30 mg × 3 days → 20 mg × 3 days → 10 mg × 2 days → 5 mg × 2 days → stop 2

Important Considerations

Glucocorticoid therapy should not be stopped without tapering in patients who have been on chronic medium/high-dose treatment (>7.5 mg prednisone equivalent daily for >3 weeks), as hypothalamic-pituitary-adrenal axis suppression should be anticipated. 1

• For acute gout specifically (short-term use), the risk of adrenal insufficiency is minimal, and abrupt discontinuation after 5-10 days is generally safe 1, 2
• However, if the patient was already on chronic corticosteroids before the acute gout episode, resume their baseline dose after treating the acute flare 1

Monitoring During Taper

• Assess for inadequate response: <20% pain improvement within 24 hours or <50% improvement at ≥24 hours warrants consideration of alternative diagnoses or adding a second agent 2
• Monitor for rebound flares during the taper, particularly in patients with severe initial attacks or polyarticular involvement 2
• Watch for short-term adverse effects including dysphoria, mood disorders, elevated blood glucose (especially in diabetics), and fluid retention 1, 2

Common Pitfalls to Avoid

• Do not interrupt ongoing urate-lowering therapy during the acute gout attack 2
• Avoid using high-dose prednisone (>10 mg/day) for prolonged prophylaxis after the acute attack resolves 2
• Do not use IV hydrocortisone at 200 mg/day dosing (the septic shock dose) for acute gout—this is excessive and inappropriate 1
• Ensure adequate stress-dose coverage only if the patient was already on chronic corticosteroids; otherwise, standard acute gout dosing is sufficient 1