What is the recommended dosage of colchicine (Colcrys) for treating acute gout attacks?

Colchicine Dosing for Acute Gout Attacks

For acute gout attacks, colchicine should be administered as a loading dose of 1.2 mg (two tablets) at the first sign of a flare followed by 0.6 mg (one tablet) one hour later, for a total dose of 1.8 mg over a 1-hour period. 1, 2

Detailed Dosing Protocol for Acute Gout

The recommended dosing regimen is based on high-quality evidence and FDA-approved labeling:

1. Initial dose: 1.2 mg (two tablets) at the first sign of gout flare
2. Follow-up dose: 0.6 mg (one tablet) one hour later
3. Maximum dose: 1.8 mg total over a 1-hour period

This low-dose regimen is as effective as higher doses but with significantly fewer gastrointestinal adverse effects 1.

Timing Considerations

• Treatment should be initiated as early as possible, ideally within 36 hours of symptom onset 1
• After 36 hours from symptom onset, colchicine's effectiveness diminishes significantly 1

Dosage Adjustments

Renal Impairment

• Dose reduction is required in patients with moderate to severe renal impairment 1, 2
• Specific adjustments should be made according to creatinine clearance levels

Drug Interactions

• Colchicine dose must be reduced when co-administered with:
  • Strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole)
  • P-glycoprotein inhibitors (e.g., cyclosporine)
• Avoid colchicine completely with strong P-glycoprotein and CYP3A4 inhibitors 2

For Patients Already on Prophylactic Colchicine

If a patient is already taking colchicine for prophylaxis and experiences an acute flare:

• Consider alternative therapy (NSAIDs or corticosteroids) 1
• If colchicine must be used, administer the acute treatment dose (1.2 mg followed by 0.6 mg)
• Wait 12 hours before resuming the prophylactic dose 2

Alternative Options for Acute Gout

When colchicine is contraindicated or not tolerated:

1. NSAIDs: Full FDA-approved anti-inflammatory doses 1
2. Corticosteroids:
   • Oral: Prednisone 0.5 mg/kg/day for 5-10 days 1
   • Intra-articular: For monoarticular gout 1

Common Pitfalls to Avoid

• Outdated high-dose regimens: Older protocols using 1.0-1.2 mg followed by 0.5-0.6 mg every 1-2 hours until relief or toxicity should be avoided 1
• Ignoring drug interactions: Failure to adjust doses with interacting medications can lead to serious toxicity 2
• Delayed treatment: Efficacy decreases significantly if started >36 hours after symptom onset 1
• Continuing treatment beyond recommended doses: Higher doses do not provide additional benefit but increase toxicity risk 1, 2

Monitoring

• Monitor for gastrointestinal symptoms (diarrhea, nausea, vomiting)
• Assess renal function before and during treatment
• Watch for signs of neuromuscular toxicity, especially in patients on statins 1

The modern low-dose colchicine regimen provides effective relief while minimizing the risk of severe adverse effects that were common with older high-dose protocols.