What is the recommended dosage and treatment regimen for colchicine (Colchicine) in patients with gout?

Colchicine Dosing Regimens for Gout Management

For acute gout attacks, colchicine should be administered as a loading dose of 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg), and should only be used if started within 36 hours of symptom onset. 1, 2, 3

Acute Gout Treatment

• The FDA-approved regimen for treating acute gout flares is 1.2 mg at the first sign of flare, followed by 0.6 mg one hour later (total dose 1.8 mg over one hour) 3
• Colchicine should only be used for gout attacks with onset within the previous 36 hours, as effectiveness significantly decreases beyond this timeframe 1, 2
• After the initial doses, continue with prophylactic dosing of 0.6 mg once or twice daily (beginning 12 hours after the initial doses) until the gout attack resolves 1, 2
• Low-dose colchicine (1.8 mg total over 1 hour) is as effective as higher doses with significantly fewer side effects 2, 3, 4
• The older high-dose regimen (1.2 mg followed by 0.6 mg hourly for 6 hours, total 4.8 mg) causes significantly more adverse events without additional benefit 3, 4

Prophylaxis Dosing

• For gout flare prophylaxis, the recommended dose is 0.6 mg once or twice daily 1, 2, 3
• The maximum recommended dose for prophylaxis is 1.2 mg/day 3
• Prophylaxis should be initiated with or just prior to starting urate-lowering therapy 1, 2
• Continue prophylaxis for:
  • At least 6 months, OR
  • 3 months after achieving target serum urate (if no tophi detected on physical exam), OR
  • 6 months after achieving target serum urate (if tophi are present) 1, 2, 5

Special Considerations and Dose Adjustments

• For patients with severe renal impairment, reduce the dose to a single dose of 0.6 mg with no repeat treatment for at least two weeks 2, 5
• For patients on dialysis, a single dose of 0.6 mg should be administered and not repeated before two weeks 5
• Dose reduction is required with concomitant use of moderate to high potency inhibitors of CYP3A4 and P-glycoprotein 2, 3
• Major drug interactions requiring dose adjustment include clarithromycin, erythromycin, cyclosporine, and disulfiram 1, 2

Efficacy and Safety

• Low-dose colchicine (1.8 mg total over 1 hour) has been shown to be effective in reducing pain in acute gout, with 38% of patients achieving at least 50% reduction in pain within 24 hours compared to 16% with placebo 3, 4
• The low-dose regimen has similar efficacy to the high-dose regimen (33% response rate) but with significantly fewer adverse events 3, 4
• Common adverse events with colchicine include diarrhea, nausea, and vomiting, which occur more frequently with high-dose regimens 3, 4
• The number needed to treat to benefit (NNTB) with low-dose colchicine is 5, while the number needed to treat to harm (NNTH) is not significantly different from placebo 4

Alternative Options When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses until complete resolution of the crisis 1
• Corticosteroids, such as prednisone 0.5 mg/kg/day for 5-10 days, then stopped or tapered over 7-10 days 1, 5
• Intra-articular injections of corticosteroids (dose varies depending on joint size) for involvement of 1-2 large joints 1

Remember that colchicine has a narrow therapeutic window, and the low-dose regimen provides the best balance of efficacy and safety for acute gout management.