What is the recommended dose and frequency of colchicine for active gout, and do you also give allopurinol?

From the Guidelines

For active gout, the recommended dose of colchicine is 1 mg initially, followed by 0.5 mg one hour later, and then 0.5 mg once or twice daily until the attack resolves, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.

• The dose and frequency of colchicine may vary depending on the severity of the attack and the patient's renal function.
• Allopurinol should not be started during an acute gout attack as it can worsen symptoms; it should be initiated after the acute attack has resolved, typically 1-2 weeks later, as suggested by the 2020 American College of Rheumatology guideline for the management of gout 1.
• Allopurinol is a urate-lowering therapy that prevents future attacks by reducing serum uric acid levels, starting at 100 mg daily and gradually increasing to achieve a target uric acid level below 6 mg/dL, usually requiring 300-600 mg daily.
• When starting allopurinol, colchicine prophylaxis (0.5-1 mg/day) is recommended for 3-6 months to prevent flares that commonly occur as uric acid levels decrease, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1.
• Patients should be advised to stay well-hydrated and avoid alcohol and purine-rich foods during acute attacks.
• The 2020 American College of Rheumatology guideline for the management of gout also recommends a treat-to-target management strategy with ULT dose titration guided by serial serum urate measurements, with an SU target of <6 mg/dl 1.
• Colchicine works by inhibiting neutrophil migration and phagocytosis, reducing the inflammatory response to urate crystals, while allopurinol inhibits xanthine oxidase, decreasing uric acid production.
• It is essential to consider the patient's renal function and adjust the dose of colchicine and allopurinol accordingly, as recommended by the 2016 updated EULAR evidence-based recommendations for the management of gout 1 and the 2020 American College of Rheumatology guideline for the management of gout 1.

From the FDA Drug Label

The recommended dose of Colchicine Tablets, USP for treatment of a gout flare is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. The maximum recommended dose for treatment of gout flares is 1.8 mg over a one hour period. Colchicine Tablets, USP may be administered for treatment of a gout flare during prophylaxis at doses not to exceed 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later. Wait 12 hours and then resume the prophylactic dose.

The recommended dose and frequency of colchicine for active gout is 1.2 mg at the first sign of the flare, followed by 0.6 mg one hour later.

• The maximum dose for treatment of gout flares is 1.8 mg over a one hour period.
• Allopurinol may be given, as colchicine is recommended upon initiation of gout flare prophylaxis with uric acid-lowering therapy, including allopurinol 2.

From the Research

Colchicine Dose and Frequency for Active Gout

• The recommended dose and frequency of colchicine for active gout is not explicitly stated in the provided studies, but according to 3 and 4, low-dose colchicine (1.2 mg or 1.8 mg) is likely to be an effective treatment for acute gout with little or no increased risk of adverse events.
• High-dose colchicine may improve symptoms, but with increased risk of harms, as reported in 3 and 4.
• The dose of colchicine may need to be adjusted in patients with renal impairment, as stated in 5, with a recommended dose of 0.48 mg or 0.5 mg for moderate renal impairment and 0.3 mg for severe renal impairment.

Use of Allopurinol

• Allopurinol is a commonly used treatment for gout, as mentioned in 6 and 7.
• The median daily dose of allopurinol at both the start and end of treatment was 300 mg, as reported in 7.
• Allopurinol is often used in combination with colchicine or other medications to treat gout, but the specific details of this combination therapy are not provided in the studies.
• Febuxostat, a novel xanthine oxidase inhibitor, is a promising alternative to allopurinol, as stated in 6, with superior ability to lower and maintain serum urate levels.

Key Considerations

• The choice of treatment for active gout depends on various factors, including the severity of symptoms, renal function, and comorbidities, as mentioned in 5 and 7.
• Colchicine and allopurinol are both effective treatments for gout, but their use should be guided by clinical judgment and individual patient needs, as reported in 3 and 4.