Colchicine Dosage for Acute Gout Flares
The recommended dosage of colchicine for acute gout flares is 1.2 mg (two tablets) at the first sign of the flare followed by 0.6 mg (one tablet) one hour later, for a maximum total dose of 1.8 mg over a one-hour period. 1, 2
Evidence-Based Dosing Regimen
The FDA-approved dosing regimen for colchicine (Colcrys) in acute gout flares is based on high-quality evidence showing that low-dose colchicine is as effective as high-dose regimens while causing fewer gastrointestinal side effects:
- Initial dose: 1.2 mg (two tablets) at the first sign of a gout flare
- Follow-up dose: 0.6 mg (one tablet) one hour later
- Maximum dose: 1.8 mg total over a one-hour period 1
This low-dose regimen has been shown to be as effective as higher doses for pain relief in acute gout flares while minimizing adverse effects 2, 3.
Special Considerations and Dose Adjustments
Renal Impairment
- eGFR < 30 ml/min: Avoid colchicine due to increased risk of toxicity 2
- eGFR 30-60 ml/min: Consider reduced doses 2, 4
Drug Interactions
- Strong CYP3A4 or P-glycoprotein inhibitors (e.g., clarithromycin, ketoconazole):
- Reduce dose to 0.6 mg (one tablet) initially, followed by 0.3 mg (half tablet) one hour later
- Do not repeat treatment for at least 3 days 1
Prophylaxis During Gout Flare
If a patient experiences a flare while on prophylactic colchicine:
- Administer the acute treatment dose (1.2 mg followed by 0.6 mg one hour later)
- Wait 12 hours before resuming the prophylactic dose 1
Common Pitfalls to Avoid
Using high-dose colchicine regimens: Older protocols recommended higher doses (e.g., 1 mg followed by 0.5 mg every 2 hours until relief or toxicity). These regimens cause more adverse effects without additional benefit 2, 3, 5.
Not adjusting for renal impairment: Failure to reduce colchicine dosage in patients with kidney disease increases the risk of toxicity 2, 4.
Overlooking drug interactions: Colchicine interacts with strong CYP3A4 inhibitors and P-glycoprotein inhibitors, requiring dose adjustments to prevent toxicity 2, 1.
Missing early signs of toxicity: Diarrhea is often the first sign of colchicine toxicity and should prompt immediate dose reduction 6.
Delayed administration: Colchicine is most effective when given early in the course of a gout flare, ideally within the first 12-24 hours 6, 7.
Monitoring and Safety
- Monitor for gastrointestinal symptoms (nausea, vomiting, diarrhea) as early signs of toxicity
- Assess renal function before initiating therapy
- Check for potential drug interactions, particularly with CYP3A4 inhibitors
- Colchicine is not an analgesic and should not be used to treat pain from other causes 1
Alternative First-Line Options
If colchicine is contraindicated or not tolerated, other first-line options include:
- NSAIDs (e.g., naproxen 500 mg twice daily)
- Oral prednisone (30-35 mg daily for 3-5 days)
- Intra-articular corticosteroid injections (for 1-2 large joints) 2
These alternatives have shown similar efficacy to colchicine for pain relief in acute gout flares 2, 5.