What is the recommended dose of colchicine for acute gout flare?

Colchicine Dosing for Acute Gout Flare

For acute gout flare, 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 dose of 1.8 mg over a one-hour period. 1

Evidence-Based Treatment Algorithm

First-Line Treatment Options:

1. Colchicine

   • Dosing regimen: 1.2 mg at first sign of flare, followed by 0.6 mg one hour later 2, 1
   • Maximum dose: 1.8 mg over a one-hour period 1
   • Timing: Most effective when started within 36 hours of symptom onset 2
   • Continuation: After initial loading doses, may continue with prophylactic dosing (0.6 mg once or twice daily) 12 hours later until gout attack resolves 2

2. Alternative dosing for countries with different tablet strengths:

   • For 0.5 mg tablets: 1.0 mg loading dose, followed by 0.5 mg one hour later, then up to 0.5 mg three times daily until attack resolves 2

Important Considerations for Colchicine Use:

• Renal impairment: Dose reduction required in moderate to severe chronic kidney disease (GFR <30 mL/min) 3, 1
• Drug interactions: Reduce dose or avoid with CYP3A4 inhibitors and P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, disulfiram) 2, 1
• Hepatic impairment: Dose adjustment needed 1
• Adverse effects: Monitor for diarrhea, which is the first sign of colchicine toxicity 4
• Patients already on prophylactic colchicine: Can still receive acute treatment but should wait 12 hours before resuming prophylactic dose 1

Alternative First-Line Options When Colchicine Is Contraindicated:

1. NSAIDs:

   • Full FDA-approved anti-inflammatory doses until gout attack completely resolves 2, 3
   • Contraindicated in renal disease, heart failure, cirrhosis, and history of GI bleeding 3

2. Corticosteroids:

   • Oral: Prednisone 0.5 mg/kg per day for 5-10 days, then stop; or 2-5 days at full dose followed by 7-10 day taper 2, 3
   • Intra-articular: For 1-2 affected large joints 2
   • Intramuscular: Triamcinolone acetonide 60 mg 2
   • Preferred in patients with renal impairment 3

Special Populations:

• Cardiovascular disease: Avoid NSAIDs; use colchicine (if renal function normal) or corticosteroids 3
• Diabetes: Monitor blood glucose when using prednisone 3
• Elderly patients: Consider lower colchicine doses, though specific adjustments aren't consistently applied in practice 5

Common Pitfalls to Avoid:

1. Exceeding recommended colchicine doses: Higher doses do not improve efficacy but increase toxicity 1, 6
2. Failure to adjust colchicine dose in renal impairment or with drug interactions 5
3. Delayed treatment: Initiating treatment beyond 36 hours of symptom onset reduces effectiveness 2
4. Using colchicine as an analgesic for pain from other causes 1
5. Interrupting urate-lowering therapy during acute flares 3

By following this evidence-based approach to colchicine dosing for acute gout flares, you can effectively manage symptoms while minimizing adverse effects and improving patient outcomes.