What is the recommended dose of colchicine (Colchicine) for treating acute gout and familial Mediterranean fever, especially in patients with impaired renal function?

Colchicine Dosing for Acute Gout and Familial Mediterranean Fever

For acute gout flares, the recommended colchicine regimen is 1.2 mg initially, followed by 0.6 mg one hour later, with a maximum first-day dose of 1.8 mg. 1 This low-dose regimen is as effective as higher doses while minimizing gastrointestinal side effects.

Acute Gout Treatment

Standard Dosing

• Initial dose: 1.2 mg (two 0.6 mg tablets)
• Follow-up dose: 0.6 mg one hour later
• Maximum first-day dose: 1.8 mg
• Treatment should begin within 36 hours of symptom onset for maximum effectiveness 2, 1

Renal Impairment Adjustments

• Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment required, but monitor closely for adverse effects 3
• Severe impairment (CrCl <30 mL/min): No dose adjustment needed for a single course, but treatment should not be repeated more than once every two weeks 3
• Dialysis patients: Reduce to a single dose of 0.6 mg, do not repeat more than once every two weeks 3

Familial Mediterranean Fever (FMF)

Standard Dosing

• Adults: 0.6 mg once or twice daily
• Children: Dose based on age and weight (not specified in provided evidence)

Renal Impairment Adjustments for FMF

• Mild to moderate impairment: Monitor closely for adverse effects, dose reduction may be necessary
• Severe impairment (CrCl <30 mL/min): Start with 0.3 mg/day; increase dose only with close monitoring 3
• Dialysis patients: Start with 0.3 mg/day; increase dose only with close monitoring 3

Drug Interactions

Colchicine has significant interactions with CYP3A4 inhibitors and P-glycoprotein inhibitors that require dose adjustments:

• Strong CYP3A4 inhibitors (e.g., clarithromycin, ritonavir):

  • For acute gout: 0.6 mg initially, no second dose 1, 3
  • For FMF: Reduce dose by 50-75% 3

• Patients with renal or hepatic impairment should not receive colchicine with CYP3A4 inhibitors due to increased risk of severe toxicity 3

Hepatic Impairment

• Mild to moderate impairment: No dose adjustment required for acute gout treatment, but monitor closely
• Severe impairment: No dose adjustment for acute treatment, but do not repeat more than once every two weeks 3

Important Considerations

• Colchicine has a narrow therapeutic window, especially in patients with renal impairment 4
• Neuromyopathy is a serious potential toxicity in renal patients, particularly when colchicine is combined with statins or cyclosporine 4
• For prophylaxis of gout flares, lower doses are used: 0.6 mg once or twice daily 2, 1
• Treatment of gout flares with colchicine is not recommended in patients already receiving prophylactic colchicine plus CYP3A4 inhibitors 3

Alternative Treatments for Acute Gout

If colchicine is contraindicated or poorly tolerated:

• NSAIDs at full anti-inflammatory doses (with PPI if appropriate)
• Corticosteroids: oral (prednisolone 30-35 mg/day for 3-5 days) or intra-articular injection 1

Remember that colchicine toxicity risk increases significantly in patients with renal impairment, especially when combined with medications that inhibit its metabolism or elimination. Close monitoring is essential in these populations.