What is the recommended dosing of colchicine (Colcrys) for the treatment and prophylaxis of acute gout?

Colchicine Dosing for Gout Treatment and Prophylaxis

For acute gout flares, colchicine should be administered at a dose of 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later, for a total dose of 1.8 mg over a one-hour period. 1, 2 For prophylaxis of gout flares, the recommended dosage is 0.6 mg once or twice daily, with a maximum recommended dose of 1.2 mg/day. 1

Acute Gout Treatment

Dosing Regimen

• Initial dose: 1.2 mg at first sign of flare
• Follow-up dose: 0.6 mg one hour later
• Maximum total dose: 1.8 mg over a one-hour period
• Timing: Most effective when started within 12-36 hours of symptom onset 2
• Efficacy decreases significantly when started later in the course of a flare

Special Considerations

• During prophylaxis: If a flare occurs while on prophylactic therapy, use the same acute treatment dosing (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming prophylactic dose 1
• Renal impairment: Avoid in severe renal impairment; consider dose reduction in moderate renal impairment 2
• Drug interactions: Avoid colchicine in patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors (clarithromycin, cyclosporin, ketoconazole, ritonavir) 2, 3

Gout Flare Prophylaxis

Dosing Regimen

• Standard dose: 0.6 mg once or twice daily 1
• Maximum dose: 1.2 mg/day
• Duration: Recommended for at least the first six months of uric acid-lowering therapy 2, 1
• Timing: Start prophylaxis upon initiation of uric acid-lowering therapy (allopurinol, febuxostat, pegloticase) 1

Dose Adjustments for Drug Interactions

When colchicine must be used with strong CYP3A4 inhibitors:

• For prophylaxis: Reduce from 0.6 mg twice daily to 0.3 mg once daily 1
• For acute treatment: Reduce to 0.6 mg (1 tablet) followed by 0.3 mg (1/2 tablet) one hour later 1

Important Safety Considerations

• Narrow therapeutic window: Colchicine has a narrow therapeutic-toxicity window with significant variability in tolerance between patients 4, 3
• Fatality risk: High fatality rates reported after acute ingestions exceeding 0.5 mg/kg; lowest reported lethal doses are 7-26 mg 3
• Toxicity progression: Colchicine toxicity typically presents in three phases:
  1. Gastrointestinal phase (10-24h): Mimicking gastroenteritis
  2. Multi-organ dysfunction phase (24h-7 days): Can lead to rapid progression and death
  3. Recovery phase: Complete recovery within weeks if patient survives 3

Alternative Treatments When Colchicine is Contraindicated

• NSAIDs: Naproxen 500mg twice daily for 5 days (avoid in renal impairment, peptic ulcer disease, uncontrolled hypertension) 2
• Corticosteroids: Oral prednisone 30-35 mg daily for 3-5 days 2
• Intra-articular corticosteroid injection: For involvement of 1-2 joints 2
• IL-1 inhibitors: For refractory cases 2

Common Pitfalls to Avoid

1. Exceeding the recommended dosage (older high-dose regimens are no longer recommended due to increased toxicity)
2. Using colchicine in patients with severe renal impairment
3. Failing to adjust dosage when co-administering with CYP3A4 or P-glycoprotein inhibitors
4. Starting colchicine too late in the course of an acute flare
5. Not providing prophylaxis when initiating urate-lowering therapy

The low-dose regimen (1.8 mg over one hour) has been shown to be as effective as higher doses with significantly fewer adverse effects 5, 4. This represents a major shift from historical high-dose regimens that had poor safety profiles 6.