What is the recommended dosing for colchicine (Colcrys) in treating acute gout and familial Mediterranean fever?

Colchicine Dosing for Acute Gout and Familial Mediterranean Fever

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

Acute Gout Management

Recommended Dosing for Acute Gout

• Initial dose: 1.2 mg (two tablets) at the first sign of a flare
• Follow-up dose: 0.6 mg (one tablet) one hour later
• Maximum dose: 1.8 mg over a one-hour period 1
• Most effective when given within 12 hours of symptom onset 2

This low-dose regimen is as effective as higher doses but with fewer gastrointestinal side effects 2, 3. The older high-dose regimen (1 g loading dose followed by 0.5 mg every 2-3 hours) caused significant gastrointestinal toxicity and is no longer recommended 4.

Prophylaxis of Gout Flares

• Standard dose: 0.6 mg once or twice daily 1
• Maximum daily dose: 1.2 mg/day 1
• Recommended duration: At least 3-6 months after starting urate-lowering therapy 2

Familial Mediterranean Fever (FMF) Dosing

Adult Dosing for FMF

• Recommended dose: 1.2 to 2.4 mg daily 1
• Dose adjustments: Increase as needed in increments of 0.3 mg/day to control disease 1
• Administration: Total daily dose may be given in one or two divided doses 1
• Minimum effective dose: 1.0 mg/day 5

Pediatric Dosing for FMF

Based on age 1:

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

Dose Modifications for Special Populations

Renal Impairment

• Assess renal function before initiating therapy 2
• Avoid colchicine if eGFR < 30 ml/min 2
• Consider reduced doses if eGFR 30-60 ml/min 2
• Colchicine toxicity risk increases significantly in renal impairment 6

Drug Interactions

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

  • For acute gout: Reduce to 0.6 mg × 1 dose, followed by 0.3 mg one hour later 1
  • For gout prophylaxis: Reduce to 0.3 mg once daily 1
  • For FMF: Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice daily) 1

• P-glycoprotein inhibitors also increase colchicine levels and toxicity risk 6

• Check for interactions with statins (increased myopathy risk) 6

Safety Considerations

Warning Signs of Toxicity

• Early signs: Gastrointestinal symptoms (nausea, vomiting, diarrhea) 6
• Serious toxicity: Multi-organ dysfunction, bone marrow suppression 6
• Lethal doses have been reported with ingestions as low as 7-26 mg 6

Common Pitfalls to Avoid

1. Using high doses in patients with renal impairment - can lead to severe toxicity even with standard doses 2, 6
2. Failing to recognize early signs of toxicity 2
3. Repeating colchicine courses too frequently in renal impairment 2
4. Not accounting for drug interactions that increase colchicine levels 2, 6
5. Using outdated high-dose regimens that cause excessive side effects 4, 3

The modern low-dose colchicine regimen (1.8 mg over 1 hour) for acute gout represents a significant improvement over historical high-dose protocols, providing similar efficacy with substantially reduced toxicity 3, 7. For both acute gout and FMF management, careful attention to renal function, potential drug interactions, and early recognition of toxicity signs are essential for safe and effective treatment.