What is the recommended dosage of colchicine (Colcrys) for acute and chronic gout management?

Colchicine Dosage for Acute and Chronic Gout Management

For acute gout flares, colchicine should be administered at a dose of 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later, with a maximum dose of 1.8 mg over a one-hour period. For prophylaxis of gout flares, the recommended dosage is 0.6 mg once or twice daily, not exceeding 1.2 mg/day. 1, 2

Acute Gout Treatment

Dosing Protocol

• Initial dose: 1.2 mg (two tablets) at first sign of gout flare
• Follow-up dose: 0.6 mg (one tablet) one hour later
• Maximum dose: 1.8 mg over a one-hour period 2

This low-dose regimen has been shown to be as effective as higher-dose protocols while causing significantly fewer adverse effects (23% vs 77% diarrhea) 1. The European League Against Rheumatism (EULAR) supports this dosing approach 1.

Timing Considerations

• Start treatment at the earliest sign of a flare for maximum effectiveness
• If taking prophylactic colchicine when a flare occurs, you may still use the acute treatment protocol (1.2 mg followed by 0.6 mg)
• After acute treatment, wait 12 hours before resuming prophylactic dosing 2

Prophylaxis of Gout Flares

Standard Prophylactic Dosing

• 0.6 mg once or twice daily (maximum 1.2 mg/day) 2
• Recommended for patients with recurrent gout attacks
• Particularly important during initiation of urate-lowering therapy 1

Duration of Prophylaxis

• Continue for at least 8 weeks when initiating urate-lowering therapy
• Ideally continue for 3-6 months after achieving target uric acid levels 1

Dose Adjustments for Special Populations

Renal Impairment

• Moderate impairment (eGFR 30-60 ml/min): Consider dose reduction
• Severe impairment (eGFR <30 ml/min): Colchicine is contraindicated 1

Drug Interactions

• Critical interactions: Reduce dose or avoid with strong CYP3A4/P-glycoprotein inhibitors (clarithromycin, cyclosporin, ketoconazole, ritonavir) 1, 2
• Statin co-administration: Monitor for myopathy risk 1, 3

Important Precautions

Therapeutic Window

• Colchicine has a narrow therapeutic index with no clear distinction between therapeutic, toxic, and lethal doses 3
• Lowest reported lethal doses are 7-26 mg 3
• Never exceed recommended doses

Common Side Effects

• Gastrointestinal symptoms (diarrhea, nausea, vomiting) are most common
• At recommended low doses, side effects are comparable to placebo 4

Contraindications

• Severe renal impairment
• Concomitant use of strong CYP3A4/P-glycoprotein inhibitors
• Combined renal and hepatic disease 1, 5

Alternative Options for Acute Gout

For patients who cannot take colchicine:

• NSAIDs (e.g., naproxen 500mg twice daily for 5 days)
• Oral corticosteroids (prednisolone 30-35 mg daily for 3-5 days)
• Intra-articular corticosteroid injection for 1-2 affected joints 1

Clinical Pearls

• Colchicine is not an analgesic and should not be used to treat pain from other causes 2
• The safety and efficacy of repeat treatment for gout flares has not been evaluated 2
• Early treatment is critical for success - keep "pills in the pocket" for immediate use at first signs of flare 6
• Avoid older high-dose colchicine regimens, which cause excessive toxicity with minimal additional benefit 7

Always assess renal function before initiating therapy and monitor for drug interactions to minimize adverse effects while maintaining efficacy.