What oral prednisone dose, formulation, and duration should be used for an adult with an acute gout flare?

Prednisone Dosing for Acute Gout Flare

For an adult with an acute gout flare, use oral prednisone 30–35 mg once daily for 5 days without taper, or alternatively 0.5 mg/kg/day for 2–5 days at full dose followed by a 7–10 day taper. 1

Standard Dosing Regimens

The American College of Rheumatology provides Level A evidence (highest quality) supporting two equally effective oral prednisone strategies for acute gout 1:

• Fixed-dose approach: Prednisone 30–35 mg once daily for 5 days, then stop abruptly 1, 2
• 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 1, 2
• Tapered approach: Prednisone 0.5 mg/kg/day for 2–5 days at full dose, followed by a 7–10 day taper 1, 2

The European League Against Rheumatism similarly recommends prednisolone 30–35 mg daily for 3–5 days as first-line therapy, noting this regimen produces significantly fewer adverse events (27%) compared to NSAIDs like indomethacin (63%) while maintaining equivalent efficacy 1, 2.

Choosing Between Dosing Strategies

For straightforward monoarticular gout without significant comorbidities, use the simpler 5-day fixed-dose regimen (30–35 mg daily) without taper. 1 This approach is practical, equally effective, and avoids the complexity of tapering schedules.

For severe attacks, polyarticular involvement, or patients at higher risk for rebound flares, use the tapered approach: 0.5 mg/kg/day for 2–5 days at full dose, then taper over 7–10 days. 1 This extended regimen reduces the risk of rebound inflammation after stopping therapy.

Alternative Corticosteroid Formulations

• Methylprednisolone dose pack (pre-packaged taper) is an appropriate alternative based on provider and patient preference 1
• Intramuscular triamcinolone acetonide 60 mg as a single injection is recommended when oral administration is not feasible or for patients requiring rapid relief 1
• Intra-articular corticosteroid injection is highly effective for involvement of 1–2 large, accessible joints, providing targeted therapy with minimal systemic exposure 1, 2

Treatment Duration and Monitoring

Continue treatment until the gout attack has completely resolved. 2 The typical 5-day course is sufficient for most patients, but more severe attacks may require the full 7–10 day tapered regimen. 1

Define inadequate response as <20% improvement in pain within 24 hours OR <50% improvement at ≥24 hours after initiating therapy. 1 If this occurs, consider combination therapy (adding colchicine) or switching to an alternative agent.

When Corticosteroids Are the Preferred First-Line Choice

Prednisone is explicitly preferred over NSAIDs and colchicine in the following clinical scenarios 1, 2:

• Severe renal impairment (eGFR <30 mL/min)—NSAIDs can precipitate acute kidney injury and colchicine carries fatal toxicity risk; prednisone requires no dose adjustment 1
• Cardiovascular disease or heart failure—NSAIDs carry cardiovascular risks 1
• Peptic ulcer disease or GI bleeding risk—corticosteroids have fewer GI adverse effects than NSAIDs 1
• Cirrhosis or hepatic impairment—NSAIDs are contraindicated 1
• Patients on anticoagulation—safer than NSAIDs 1
• NPO status or inability to take oral medications—use parenteral corticosteroids 1

Combination Therapy for Severe Attacks

For severe acute gout with polyarticular involvement, use initial combination therapy: oral prednisone plus colchicine, or intra-articular steroids combined with any other oral anti-inflammatory agent. 1, 2 Combination therapy is more effective than monotherapy for severe attacks and is strongly recommended by the American College of Rheumatology. 1

Absolute Contraindications

• Systemic fungal infections—corticosteroids are absolutely contraindicated 1, 2
• Active uncontrolled infection—avoid due to immune suppression 1

Important Safety Considerations

Short-term corticosteroid use (5–10 days) is associated with manageable adverse effects 1:

• Dysphoria and mood disorders
• Transient hyperglycemia (monitor glucose closely in diabetics and adjust medications proactively) 1
• Fluid retention
• Minimal bone density risk with short courses 1

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 For prophylaxis, low-dose prednisone (≤10 mg/day) is a second-line option for 3–6 months if colchicine and NSAIDs are contraindicated. 1, 2

Common Pitfalls to Avoid

• Do NOT interrupt ongoing urate-lowering therapy during an acute flare—continue it with appropriate anti-inflammatory coverage 1
• Do NOT delay treatment—initiate therapy within 24 hours of symptom onset for optimal efficacy 1
• Do NOT use colchicine in severe renal impairment (eGFR <30 mL/min) or with strong CYP3A4/P-glycoprotein inhibitors (cyclosporine, clarithromycin)—fatal toxicity can occur 1, 2
• Do NOT expect immediate relief within 6 hours—meaningful clinical improvement typically requires 24–48 hours 1