From the Guidelines
For gout worsening despite 3 days of prednisone, I recommend switching to a different anti-inflammatory approach, such as colchicine 0.6 mg twice daily for 1-2 days, then once daily for 7-10 days, or an NSAID like naproxen 500 mg twice daily for 7-10 days if there are no contraindications, as suggested by the 2020 American College of Rheumatology guideline for the management of gout 1.
Key Considerations
- The patient should be well-hydrated and continue any prescribed urate-lowering therapy like allopurinol or febuxostat without interruption during the flare, as recommended by the 2012 American College of Rheumatology guidelines for management of gout 1.
- Apply ice to affected joints for 20-minute intervals several times daily to help with pain and inflammation.
- If symptoms persist beyond 7 days of appropriate therapy or if multiple joints become involved, the patient should be reevaluated promptly.
Treatment Options
- Colchicine: 0.6 mg twice daily for 1-2 days, then once daily for 7-10 days, as recommended by the 2017 American College of Physicians guideline for the management of acute and recurrent gout 1.
- NSAID: naproxen 500 mg twice daily for 7-10 days if there are no contraindications, as suggested by the 2020 American College of Rheumatology guideline for the management of gout 1.
- Increasing prednisone to 30-40 mg daily for 3-5 days followed by a taper over 10-14 days for severe cases, as recommended by the 2017 American College of Physicians guideline for the management of acute and recurrent gout 1.
Lifestyle Modifications
- Weight loss if appropriate and avoidance of alcohol (especially beer and spirits) and sugar-sweetened drinks, heavy meals and excessive intake of meat and seafood, as recommended by the 2017 updated EULAR evidence-based recommendations for the management of gout 1.
- Regular exercise and low-fat dairy products should be encouraged.
- Consumption of coffee and cherries may be beneficial in reducing the frequency of acute gout, as suggested by the 2017 updated EULAR evidence-based recommendations for the management of gout 1.
From the Research
Management of Gout Worsening with 3 Days of Prednisone
- Gout is an inflammatory arthritis that typically presents as acute onset, recurrent, monoarticular pain, and its management involves treating the acute flare and preventing future flares 2.
- Therapeutic options for treating the acute flare include colchicine, nonsteroidal anti-inflammatory drugs, and corticosteroids, such as prednisone 2, 3.
- Corticosteroids, like prednisone, are efficacious in the treatment of acute gout and pose little risk when used in the short-term, making them a preferred option in patients with contraindications to colchicine or NSAIDs 3.
- However, worsening of gout after 3 days of prednisone may indicate the need to reassess the treatment plan and consider alternative options, such as adjusting the dose or duration of prednisone, or adding other medications like colchicine or NSAIDs 2, 3.
- It is essential to consider individual patient-specific characteristics, including comorbidities, concomitant medications, and renal function, when selecting treatment for gout, especially in older adults 3.
- Urate-lowering therapy with allopurinol or febuxostat should be initiated after flare remission to prevent future flares, with careful consideration of dose adjustments in patients with renal impairment 2, 3.