What is the recommended systemic glucocorticoid regimen for an acute gout flare, and how should it be adjusted for patients with renal impairment, diabetes, hypertension, or peptic ulcer disease, including intra‑articular options?

Systemic Glucocorticoid Regimen for Acute Gout Flare

For an acute gout flare, use oral prednisone 30–35 mg daily for 5 days without taper, or alternatively prednisone 0.5 mg/kg/day for 2–5 days followed by a 7–10 day taper if the attack is severe or polyarticular. 1, 2, 3

Standard Oral Corticosteroid Dosing

The American College of Rheumatology strongly recommends glucocorticoids (oral, intramuscular, or intra-articular) as first-line therapy for gout flares, with efficacy equal to NSAIDs and colchicine but often safer in patients with comorbidities. 1, 2

Two Evidence-Based Regimens:

• Fixed-dose approach: Prednisolone 30–35 mg once daily for 5 days, then stop abruptly—this is simpler and equally effective for most patients 1, 2, 3

• Weight-based approach: Prednisone 0.5 mg/kg/day (approximately 30–35 mg for average adults) for 5–10 days at full dose then stop, OR give for 2–5 days at full dose followed by 7–10 day taper 2, 3

Use the tapered approach for severe attacks, polyarticular involvement, or patients at higher risk for rebound flares. 3 Use the simpler 5-day course without taper for straightforward monoarticular cases with no significant comorbidities. 3

Adjustments for Renal Impairment

Corticosteroids are the safest first-line option for patients with severe renal impairment (eGFR <30 mL/min) because NSAIDs can precipitate acute kidney injury and colchicine carries fatal toxicity risk in this population. 2, 3, 4, 5

Key Advantages in Renal Disease:

• No dose adjustment required for corticosteroids regardless of renal function 2, 3

• NSAIDs must be avoided in severe CKD due to risk of acute kidney injury and cardiovascular complications 2, 3

• Colchicine should be avoided entirely when eGFR <30 mL/min or when patients are on strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin) due to fatal toxicity risk 2, 6, 7

Use the standard dose of prednisone 30–35 mg daily for 5 days, or the 2–5 day full dose followed by 7–10 day taper for more severe attacks in patients with renal impairment. 2, 3

Adjustments for Diabetes

Short-term corticosteroids (5–10 days) can significantly elevate blood glucose levels, requiring proactive monitoring and adjustment of diabetic medications. 2, 3

Management Strategy:

• Monitor blood glucose levels more frequently during corticosteroid therapy 2

• Adjust insulin or oral hypoglycemic doses proactively rather than reactively 2

• Use the standard prednisone dose (30–35 mg daily for 5 days)—do not reduce the dose, as short courses pose acceptable risk when properly monitored 2, 3

• The metabolic effects are temporary and resolve after discontinuation 2

Adjustments for Hypertension

Corticosteroids are explicitly preferred over NSAIDs in patients with hypertension because NSAIDs carry cardiovascular risks including blood pressure elevation and increased risk of myocardial infarction and stroke. 2, 3, 8

Key Considerations:

• Short-term corticosteroids may cause fluid retention, requiring monitoring but not dose reduction 2, 3

• Use standard dosing: prednisone 30–35 mg daily for 5 days 2, 3

• NSAIDs should be avoided in patients with cardiovascular disease or heart failure 2, 8, 4

• Colchicine is considered safe and potentially reduces the risk of myocardial infarction in patients with cardiovascular disease 8

Adjustments for Peptic Ulcer Disease

Corticosteroids are safer than NSAIDs in patients with peptic ulcer disease history, though proton pump inhibitor co-therapy should be considered. 2, 3

Management Approach:

• Use standard prednisone dosing (30–35 mg daily for 5 days) with concurrent PPI therapy 3

• NSAIDs are contraindicated in active peptic ulcer disease 6

• For patients with active peptic ulcer disease or recent GI bleeding who cannot take oral medications, IV corticosteroids are the treatment of choice 3

• Short courses (5–10 days) of corticosteroids pose minimal GI risk compared to NSAIDs 3, 5

Intra-Articular Corticosteroid Options

Intra-articular corticosteroid injection is highly effective for monoarticular or oligoarticular gout involving 1–2 large accessible joints, providing targeted therapy with minimal systemic effects. 1, 2, 3

Specific Recommendations:

• For involvement of 1–2 large joints, intra-articular injection is an appropriate alternative to oral corticosteroids 1, 2, 3

• Dose varies depending on joint size—larger joints require higher doses 3

• Intra-articular steroids can be combined with any other oral modality for severe attacks 2, 3

• Joint aspiration should be performed before injection to confirm crystal-proven gout and exclude septic arthritis 7

Parenteral Corticosteroid Options

For patients unable to take oral medications (NPO status, surgical conditions, intractable vomiting), parenteral glucocorticoids are strongly recommended over IL-1 inhibitors or ACTH. 1, 2, 3

Parenteral Dosing:

• Intramuscular triamcinolone acetonide 60 mg as a single injection 2, 3

• Intramuscular or IV methylprednisolone 0.5–2.0 mg/kg (approximately 40–140 mg for most adults), with repeat doses as clinically indicated 2, 3

• Parenteral glucocorticoids are safer and more cost-effective than IL-1 inhibitors for severe gout 3

Combination Therapy for Severe Attacks

For severe acute gout with multiple joint involvement, initial combination therapy is appropriate, including oral corticosteroids plus colchicine, or intra-articular steroids with any other oral modality. 1, 2, 3

• Combination therapy is more effective than monotherapy for severe polyarticular attacks 2, 3

• Acceptable combinations include: oral corticosteroids + colchicine, intra-articular steroids + any other modality, or colchicine + NSAIDs 1, 2

Absolute Contraindications to Corticosteroids

Systemic fungal infections are an absolute contraindication to corticosteroid therapy. 2, 3

Current active infection is a contraindication due to immune suppression risk. 3

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 2, 3

• Do not interrupt ongoing urate-lowering therapy during an acute gout attack—continue it with appropriate anti-inflammatory coverage 3

• Do not delay treatment—pharmacologic treatment should be initiated within 24 hours of acute gout attack onset for optimal efficacy 2, 3

• Do not use NSAIDs in severe renal impairment, cardiovascular disease, heart failure, or active peptic ulcer disease 2, 3, 8, 4

• Do not use standard-dose colchicine without significant dose reduction in renal impairment—the risk of toxicity outweighs benefits 2, 3