Colchicine Dosage for Acute Gout Attacks and Prophylaxis
For acute gout attacks, colchicine should be administered as 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. For prophylaxis, the recommended dosage is 0.6 mg once or twice daily, not exceeding 1.2 mg per day. 1
Acute Gout Attack Treatment
The FDA-approved dosing regimen for acute gout flares consists of:
- 1.2 mg (two tablets) at the first sign of a flare
- 0.6 mg (one tablet) one hour later
- Maximum total dose: 1.8 mg over a one-hour period 1
This low-dose regimen has been shown to be as effective as higher doses with fewer gastrointestinal side effects 2. The efficacy of this regimen was demonstrated in a phase III randomized controlled trial where it significantly reduced pain within 24 hours compared to placebo 3.
Important considerations:
- Administer as early as possible in the course of an acute attack ("pills in the pocket" approach) 4
- Colchicine is not an analgesic and should not be used to treat pain from other causes 1
- The safety of repeated treatments for gout flares has not been evaluated 1
Prophylaxis of Gout Flares
For preventing gout flares, the recommended dosage is:
- 0.6 mg once or twice daily for adults and adolescents older than 16 years
- Maximum daily dose: 1.2 mg/day 1
Prophylactic therapy is particularly beneficial:
- When initiating uric acid-lowering therapy (allopurinol, febuxostat, pegloticase)
- For at least the first six months of uric acid-lowering therapy 1
- For patients with recurrent gout attacks (≥2 per year) 2
Dose Adjustments for Special Populations
Renal Impairment
- Assess renal function before initiating therapy
- Avoid colchicine if eGFR < 30 ml/min
- Consider reduced doses if eGFR 30-60 ml/min 2
- Standard doses in renal impairment can lead to severe toxicity even with low doses 2
Drug Interactions
Dose adjustment is necessary when colchicine is co-administered with CYP3A4 and/or P-glycoprotein inhibitors:
For strong CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole, ritonavir):
- Prophylaxis: Reduce to 0.3 mg once daily (from 0.6 mg twice daily)
- Acute flare: Reduce to 0.6 mg (1 tablet) followed by 0.3 mg (1/2 tablet) one hour later 1
Monitoring and Safety Considerations
Signs of Toxicity
- Watch for early signs of toxicity, particularly gastrointestinal symptoms 2, 5
- Diarrhea typically occurs after a median time of 24 hours and often precedes pain relief 6
- Colchicine has a narrow therapeutic index with no clear distinction between therapeutic, toxic, and lethal doses 5
Contraindications
- Avoid combining NSAIDs and colchicine due to synergistic gastrointestinal toxicity 2
- Avoid in patients with severe renal or hepatic impairment 2, 5
- Use caution in elderly patients 7
Common Pitfalls to Avoid
Exceeding recommended doses: The lowest reported lethal doses of oral colchicine are 7-26 mg 5
Failing to adjust doses for renal impairment: Using standard doses in patients with renal dysfunction can lead to toxicity 2
Overlooking drug interactions: Particularly with CYP3A4 inhibitors like clarithromycin and ketoconazole, which can significantly increase colchicine levels 1, 5
Repeating colchicine courses too frequently: Especially in patients with renal impairment, which increases toxicity risk 2
Missing early signs of toxicity: Gastrointestinal symptoms are early warning signs that should prompt discontinuation 2, 5
By following these evidence-based dosing recommendations and monitoring guidelines, colchicine can be used effectively and safely for both acute gout management and prophylaxis.