What is the recommended dose of Colchicine (colchicine) for an acute gout attack?

Colchicine Dosing for Acute Gout Attack

For an acute gout attack, the recommended dose of colchicine is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later, for a maximum total dose of 1.8 mg over a one-hour period. 1

Evidence-Based Dosing Protocol

The American College of Rheumatology (ACR) guidelines support this low-dose colchicine regimen, which represents a significant shift from older high-dose protocols that caused more adverse effects 2. This dosing recommendation is based on high-quality evidence showing that:

• Low-dose colchicine (1.8 mg total over 1 hour) is as effective as high-dose colchicine for treating acute gout flares 3
• The low-dose regimen has a safety profile similar to placebo, while high-dose regimens cause significantly more adverse effects 3
• Treatment should be initiated within 36 hours of symptom onset for maximum effectiveness 2

Important Considerations for Colchicine Use

Timing of Administration

• Colchicine is most effective when started within 36 hours of symptom onset 2
• If the patient is already on prophylactic colchicine, choose an alternative therapy (NSAID or corticosteroid) 2

Dose Adjustments

• Dose must be adjusted for patients with renal impairment, hepatic dysfunction, or taking interacting medications 1
• For patients taking strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole), reduce dose to 0.6 mg initially followed by 0.3 mg one hour later 1

Adverse Effects

• At the recommended low dose, colchicine has an adverse effect profile similar to placebo 4, 3
• Common adverse effects with higher doses include diarrhea, nausea, vomiting, and abdominal pain 3
• The low-dose regimen (1.8 mg over 1 hour) significantly reduces gastrointestinal side effects compared to traditional high-dose regimens 3

Alternative Treatments for Acute Gout

If colchicine is contraindicated or not tolerated, consider:

1. NSAIDs: Full FDA-approved doses until the attack resolves 2
2. Corticosteroids:
   • Oral: Prednisone 0.5 mg/kg per day for 5-10 days 2
   • Intra-articular: Dose varies by joint size 2
   • Intramuscular: Triamcinolone acetonide 60 mg 2

Prophylaxis After Acute Attack

After treating the acute attack, consider prophylaxis:

• Low-dose colchicine: 0.6 mg once or twice daily 2, 1
• Continue prophylaxis for at least 3-6 months after achieving target serum urate levels 2

Common Pitfalls to Avoid

1. Using outdated high-dose regimens: The traditional high-dose colchicine regimen (4.8 mg over 6 hours) causes significantly more adverse effects with no additional benefit 3

2. Delaying treatment: Efficacy decreases when treatment is initiated more than 36 hours after symptom onset 2

3. Failing to adjust dose for drug interactions: Colchicine interacts with many medications, particularly strong CYP3A4 inhibitors, requiring dose adjustments 1

4. Continuing colchicine despite adverse effects: If diarrhea, nausea, or vomiting occurs, colchicine should be stopped immediately 3

5. Using colchicine in patients with severe renal or hepatic impairment without appropriate dose adjustments 1

The low-dose colchicine regimen (1.2 mg followed by 0.6 mg one hour later) represents the optimal balance of efficacy and safety for acute gout attacks based on current evidence.