Robby asked
I’m in a two month long gout attack. Went through a 6- pack of methylprednisolone back in two days. Also tried prednisone for 5-Days and I couldn’t walk on the 5th day. Colchicine reduces swelling, but the pain brought it back, followed by good ole’ indomethacin. I still had uric crystal pockets! Now, a mixture of indomethacin, prednisone, and colchicine all at once! Is this safe?
Answer
According to the American College of Rheumatology Guidelines for Management of Gout (1) there are three drug classes that are the mainstay of therapy when it comes to the treatment (not prophylaxis) of gout. They are:
- Colchicine
- NSAIDs (e.g. indomethacin, Celebrex)
- Oral or parental corticosteroids (e.g. prednisone, methylprednisolone)
There are many factors that you omitted in your question to take into account when deciding therapy for an acute gout attack (e.g. dose of prednisone you were taking, other medications you are on etc...). It is important to discuss your potential options with your doctor.
In addition, it is very important to mention whether or not you are taking a prophylactic medication, like allopurinol. If you are, it may be the culprit in terms of causing an acute attack but it is very important not to discontinue your prophylactic medication if you do get one (2).
Nevertheless, when it comes to what the guidelines say, any of the above options as a single agent (e.g. just colchicine) are recommended first-line options for an acute attack. However, these are typically only effective with mild to moderate attacks of gout, and generally only those involving a few small joints or one large joint.
Steroid Not Working For Gout
For many individuals, a single drug, like prednisone, may not be effective for treating an acute gout attack. In cases of a severe attack, the guidelines suggest combination therapy:
- Colchicine and NSAIDs
- Corticosteroids and colchicine
- Intra-articular steroids with oral corticosteroids, NSAIDs, or colchicine
The above combinations are thought to be relatively safe when used together. The only combination that is recommended to be avoided is:
- Systemic corticosteroids (like prednisone or methylprednisolone) and NSAIDs due to potential synergistic gastrointestinal adverse effects, such as bleeding (2)
In your case, indomethacin (a NSAID) and prednisone increase your risk of adverse GI effects. They should not be used together unless specifically recommended by your doctor, and even then, you should be appropriately monitored.
As a side note, what you mentioned about your steroid dose may indicate inadequate dosing. The guidelines suggest a 5 to 10 day course of steroids, between 30 to 40 mg per day. You mentioned only a 2 day course and a 5 day course with no dose indicated.
It is important to discuss with your doctor the trouble you are having managing your gout attack. With prednisone not working, you need to evaluate other options:
- Another course of steroids at the recommended doses.
- Combination therapy at the recommended doses (e.g. steroids with colchicine).
- Intra-articular steroids (injections) at the site of pain and inflammation.
- Adding on a prophylactic therapy to decrease uric acid levels over time (even though they can initially exacerbate an attack).
As mentioned above, the one thing to be aware of in your specific case is the combination of steroids and NSAIDs. The combination is well documented to increase the risk of GI bleeds (3).
