What is the recommended dosage of colchicine (Colcrys) for a gout flare-up?

Colchicine Dosage for Acute Gout Flares

For acute gout flares, the recommended dosage of colchicine 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 dose of 1.8 mg over a one-hour period. 1

First-Line Treatment Options

• Colchicine is most effective when administered within 12 hours of symptom onset 2
• The "pill in the pocket" approach is recommended for fully informed patients to self-medicate at the first warning symptoms 2
• The maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period 1
• Higher doses have not been found to be more effective and may increase toxicity 1, 3

Dosing Algorithm

1. Initial dose: 1.2 mg (two tablets) at the first sign of flare 1
2. Follow-up dose: 0.6 mg (one tablet) one hour later 1
3. Total maximum dose: 1.8 mg within the first hour 1, 4
4. If on prophylactic colchicine: May still use the acute treatment dosing, then wait 12 hours before resuming prophylactic dosing 1

Important Contraindications and Precautions

• Renal impairment: Avoid colchicine in patients with severe renal impairment (GFR <30 mL/min) 2, 5
• Drug interactions: Do not give colchicine to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 2, 1
• Hepatic impairment: Dose adjustment may be necessary in patients with hepatic dysfunction 1
• Statin therapy: Be aware of potential neurotoxicity and/or muscular toxicity when colchicine is used with statins 5

Alternative Options if Colchicine is Contraindicated

• NSAIDs: Full FDA-approved dose until the gouty attack has completely resolved 2
• Oral corticosteroids: 30-35 mg/day of prednisolone for 3-5 days 2, 5
• Intra-articular corticosteroids: Effective for monoarticular gout 5

Evidence Quality and Considerations

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg) was as effective as high-dose colchicine (4.8 mg) but with significantly fewer side effects 2, 3
• European guidelines recommend 1 mg followed by 0.5 mg one hour later, which aligns with the FDA-approved dosing in the US 2, 1
• Older dosing regimens using higher doses of colchicine are no longer recommended due to increased toxicity without improved efficacy 4, 6

Prophylactic Dosing (After Acute Flare Resolution)

• For prophylaxis during urate-lowering therapy: 0.6 mg once or twice daily 1, 7
• Maximum recommended dose for prophylaxis: 1.2 mg/day 1
• Prophylactic therapy is recommended for at least the first six months of urate-lowering therapy 1, 8

Common Pitfalls to Avoid

• Using excessive doses of colchicine, especially in patients with renal impairment 6
• Failing to adjust doses in patients taking interacting medications 1
• Delaying treatment beyond 12-36 hours after symptom onset, which significantly reduces effectiveness 2
• Using colchicine as an analgesic for pain from other causes 1