What is the recommended dosing for colchicine (Colcrys) in patients with acute and chronic gout, including those with impaired renal function?

Colchicine Dosing for Acute and Chronic Gout

For acute gout flares, colchicine should be administered as a loading dose of 1.2 mg (two 0.6 mg tablets) followed by 0.6 mg one hour later, with treatment initiated within 12-36 hours of symptom onset for maximum effectiveness. 1

Acute Gout Treatment

First-Line Dosing for Acute Gout:

• Initial dose: 1.2 mg (two 0.6 mg tablets)
• Follow-up dose: 0.6 mg one hour later
• Total first-day dose: 1.8 mg
• Continue with 0.6 mg once or twice daily starting 12 hours after the loading dose until the attack resolves 1

Timing Considerations:

• Most effective when started within 12 hours of symptom onset 1
• Should not be initiated if symptoms began >36 hours prior 1

Renal Impairment Dosing for Acute Gout:

• Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed, but monitor closely for adverse effects
• Severe impairment (CrCl <30 mL/min): Treatment course should not be repeated more than once every two weeks
• Dialysis patients: Reduce to a single dose of 0.6 mg, do not repeat more than once every two weeks 2

Prophylaxis for Recurrent Gout

Standard Prophylactic Dosing:

• 0.5-1 mg daily 1
• In US: 0.6 mg once or twice daily 1

Renal Impairment Dosing for Prophylaxis:

• Mild to moderate impairment: No dose adjustment required, but monitor closely
• Severe impairment (CrCl <30 mL/min): Start with 0.3 mg/day
• Dialysis patients: 0.3 mg twice weekly with close monitoring 2

Important Considerations and Contraindications

Drug Interactions:

• Avoid colchicine in patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors (e.g., cyclosporin, clarithromycin) 1
• Significant dose reductions required with moderate CYP3A4 inhibitors 2

Toxicity Monitoring:

• Diarrhea is the first sign of colchicine toxicity - reduce dose if this occurs 3
• Monitor for neurotoxicity and muscular toxicity, especially in patients on statins or with renal impairment 1

Alternative Treatments:

• If colchicine is contraindicated or not tolerated, consider:
  • NSAIDs (with PPI if appropriate)
  • Oral corticosteroids (30-35 mg/day prednisolone for 3-5 days)
  • Intra-articular corticosteroid injection 1

Algorithm for Treatment Selection

1. For acute gout flare within 12-36 hours of onset:

   • Use colchicine loading dose (1.2 mg followed by 0.6 mg one hour later)
   • Continue with 0.6 mg once or twice daily until resolution

2. For patients with severe renal impairment:

   • Consider corticosteroids as first-line therapy (safer option) 1
   • If using colchicine, reduce dose and frequency as noted above

3. For prophylaxis during urate-lowering therapy:

   • Use colchicine 0.5-1 mg daily for at least 6 months
   • Reduce dose in renal impairment
   • Continue until 3-6 months after achieving target serum urate level 1

The evidence strongly supports the low-dose colchicine regimen for acute gout, which is as effective as higher doses but with significantly fewer gastrointestinal side effects 4, 5. This represents a significant shift from historical high-dose regimens that often caused severe toxicity 6.