What are the dosing guidelines for colchicine (Colcrys) in patients with acute gout or familial Mediterranean fever?

Colchicine Dosing Guidelines

For acute gout flares, colchicine should be administered at a dose of 1.2 mg (two tablets) at the first sign of a flare, followed by 0.6 mg (one tablet) one hour later, with a maximum dose of 1.8 mg over a one-hour period. 1, 2, 3

Acute Gout Flare Treatment

Low-Dose Regimen (Preferred)

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

This low-dose regimen represents a significant shift from historical high-dose colchicine regimens and is supported by evidence showing similar efficacy with fewer adverse effects compared to higher doses 2, 4.

Timing Considerations

• Most effective when administered within 24 hours of symptom onset
• If taking colchicine prophylactically when a flare occurs:
  • Take 1.2 mg at first sign of flare followed by 0.6 mg one hour later
  • Wait 12 hours before resuming prophylactic dosing 1

Prophylaxis of Gout Flares

• Standard dose: 0.6 mg once or twice daily (maximum 1.2 mg/day) 1, 3
• Duration of prophylaxis:
  • At least 6 months when starting urate-lowering therapy (Evidence A) 2
  • 3 months after achieving target serum urate in patients without tophi 2, 3
  • 6 months after achieving target serum urate in patients with resolved tophi 2, 3

Familial Mediterranean Fever (FMF) Dosing

Adults

• Recommended dose: 1.2 to 2.4 mg daily 1
• May be administered in one or two divided doses
• Dose adjustments: Increase as needed in 0.3 mg/day increments to control disease 1

Pediatric Patients (4 years and older)

• Ages 4-6 years: 0.3 mg to 1.8 mg daily
• Ages 6-12 years: 0.9 mg to 1.8 mg daily
• Ages >12 years: 1.2 mg to 2.4 mg daily 1

Dose Modifications for Special Populations

Renal Impairment

• Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed for acute flares, but monitor closely
• Severe impairment (CrCl <30 mL/min):
  • For acute flares: Same dose but limit treatment course to once every two weeks
  • For prophylaxis: Start with 0.3 mg/day 1, 3
• Dialysis patients:
  • For acute flares: Single dose of 0.6 mg, no more than once every two weeks
  • For prophylaxis: 0.3 mg twice weekly 1

Drug Interactions

Dose adjustments are necessary when colchicine is co-administered with CYP3A4 and/or P-glycoprotein inhibitors 1, 3:

• For acute gout flares:

  • With strong inhibitors: 0.6 mg (1 tablet) initially, followed by 0.3 mg (1/2 tablet) 1 hour later
  • Do not repeat treatment for at least 3 days

• For prophylaxis:

  • With strong inhibitors: Reduce dose by 50-75% (e.g., 0.3 mg once daily or every other day)

Common Adverse Effects and Precautions

• Gastrointestinal effects (diarrhea, nausea, vomiting) are most common, especially with higher doses 4, 3
• Monitor for myopathy and rhabdomyolysis, particularly in patients with renal impairment or those taking CYP3A4 inhibitors 1
• Low-dose regimens have significantly better safety profiles than historical high-dose regimens 4, 5

Key Clinical Pearls

• The therapeutic window for colchicine is narrow; adherence to recommended dosing is critical to minimize toxicity 6
• Avoid starting urate-lowering therapy during an acute attack without appropriate prophylaxis 3
• Continue colchicine prophylaxis when initiating urate-lowering therapy to prevent flares 3
• Do not use colchicine as an analgesic for pain from other causes 1
• Always assess renal function before prescribing colchicine 3, 1

The shift to low-dose colchicine regimens represents an important advance in gout management, maintaining efficacy while significantly reducing adverse effects 2, 4.