Can you take colchicine and allopurinol (Nonsteroidal Anti-Gout (NSAG)) at the same time?

Taking Colchicine and Allopurinol Together

Yes, colchicine and allopurinol can and should be taken together when initiating urate-lowering therapy, as colchicine prophylaxis significantly reduces the frequency and severity of gout flares during the first 6 months of allopurinol treatment. 1, 2

Rationale for Combination Therapy

• The FDA label for allopurinol explicitly states: "An increase in acute attacks of gout has been reported during the early stages of administration of allopurinol tablets... Accordingly, maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun." 2

• High-strength evidence shows that prophylaxis with colchicine reduces the risk for acute gout attacks in patients initiating urate-lowering therapy like allopurinol. 1

• A randomized, placebo-controlled trial demonstrated that patients receiving colchicine prophylaxis had significantly fewer gout attacks (33%) compared to placebo recipients (77%) during allopurinol initiation (p=0.008). 1, 3

Recommended Protocol

1. Dosing:

   • Colchicine: 0.5-1 mg daily for prophylaxis 1
   • Allopurinol: Start at 100 mg daily and increase by 100 mg increments every 2-4 weeks until target serum urate level <6 mg/dL is reached 4, 2

2. Duration of Prophylaxis:

   • Continue colchicine prophylaxis for at least 6 months after initiating allopurinol 1, 4
   • Moderate-strength evidence suggests prophylaxis should be longer than 8 weeks 1

3. Monitoring:

   • Monitor serum uric acid levels every 2-4 weeks during dose titration 4
   • Target serum uric acid level should be below 6 mg/dL (360 μmol/L) 4

Important Considerations

Potential Adverse Effects

• Diarrhea is more common with colchicine (43%) than placebo (4%) 1
• Lower dose colchicine (0.6 mg/day) provides similar prophylactic benefits with fewer adverse events compared to regular-dose colchicine (1.2 mg/day) 5

Dose Adjustments

• Reduce colchicine dose in patients with renal impairment 1, 4
• Avoid co-prescription of colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors 1
• Be cautious of potential neurotoxicity and/or muscular toxicity when using colchicine with statins 1, 6

Recent Evidence

• A 2023 randomized controlled trial confirmed that colchicine is superior to placebo in preventing gout flares during the first 6 months of allopurinol therapy, even when using the "start-low go-slow" allopurinol dosing approach 7

Common Pitfalls to Avoid

1. Not using prophylaxis: Initiating allopurinol without colchicine prophylaxis significantly increases the risk of gout flares, which may lead to poor medication adherence.

2. Stopping prophylaxis too early: Evidence from clinical trials shows that discontinuing prophylaxis at 8 weeks results in a spike in acute attacks, with approximately double the proportion of patients reporting an attack. 1

3. Using excessive colchicine doses: Lower doses (0.5-0.6 mg daily) are often sufficient for prophylaxis and have fewer side effects than higher doses. 5

4. Ignoring drug interactions: Be vigilant about potential interactions between colchicine and other medications, particularly statins and drugs that inhibit P-glycoprotein or CYP3A4. 1, 6

5. Discontinuing therapy during flares: Allopurinol should be continued even during acute gout flares. 4