What are the doses for colchicine in acute gout attacks and febuxostat (febuxostat) after a gout flare?

Dosing for Colchicine in Acute Gout Attacks and Febuxostat After Flare

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 febuxostat should be initiated at a low dose with flare prophylaxis using colchicine 0.6 mg once or twice daily for at least 6 months. 1, 2, 3

Colchicine Dosing for Acute Gout Attacks

• Colchicine should be started as early as possible, ideally within 12-36 hours of flare onset for maximum effectiveness 1, 2
• The recommended dosing regimen is:
  • Loading dose: 1.2 mg (two 0.6 mg tablets) at the first sign of flare
  • Followed by: 0.6 mg (one tablet) one hour later
  • Total dose: 1.8 mg over a one-hour period 2, 3
• 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 2
• Low-dose colchicine (1.8 mg total over 1 hour) is as effective as higher doses with significantly fewer side effects 2

Special Considerations for Colchicine

• Colchicine should be avoided in patients with severe renal impairment 1
• For patients with moderate renal impairment, reduce the dose to 0.6 mg with no repeat treatment for at least two weeks 2
• Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1, 2
• If colchicine is contraindicated, alternative options include:
  • NSAIDs at full FDA-approved doses until complete resolution of the crisis 1, 2
  • Oral corticosteroids (30-35 mg/day of equivalent prednisolone for 3-5 days) 1
  • Intra-articular corticosteroid injections for involvement of 1-2 large joints 1, 2

Febuxostat After Gout Flare

• Febuxostat should be initiated at a low dose and then titrated upwards until the serum uric acid (SUA) target is reached 1
• The target SUA level should be maintained at <6 mg/dL (360 μmol/L) 1, 4
• A lower SUA target (<5 mg/dL; 300 μmol/L) is recommended for patients with severe gout (tophi, chronic arthropathy, frequent attacks) 1

Flare Prophylaxis When Starting Febuxostat

• Prophylaxis against flares is essential when initiating febuxostat as urate-lowering therapy (ULT) 5, 6
• Recommended prophylactic treatment is colchicine, 0.6 mg once or twice daily 1, 2, 5
• Prophylaxis should be continued for at least 6 months during ULT 1, 2, 6
• Studies show that 6 months of prophylaxis provides greater benefit than shorter durations (e.g., 8 weeks) 6
• If colchicine is not tolerated or contraindicated, low-dose NSAIDs or low-dose prednisone (approximately 7.5 mg daily) can be used as alternatives 1, 5

Monitoring and Adjustments

• Monitor SUA levels regularly during febuxostat therapy 1
• Febuxostat has been shown to be more effective than allopurinol 300 mg daily in reducing SUA levels below 6 mg/dL 4
• No dose adjustment of febuxostat is required in mild-to-moderate renal impairment 4
• Patients should be educated that acute flares may occur when initiating ULT despite prophylaxis, but these typically decrease over time as SUA levels are consistently maintained below target 6, 4

Common Pitfalls to Avoid

• Failing to start colchicine within 36 hours of symptom onset significantly reduces its effectiveness 2
• Interrupting ongoing febuxostat therapy during an acute gout attack is not recommended 1
• Inadequate duration of flare prophylaxis when initiating ULT often leads to breakthrough flares 6
• Not adjusting colchicine dose in patients with renal impairment or those on interacting medications can lead to toxicity 1, 2
• Failing to maintain long-term ULT after resolution of acute symptoms leads to recurrent flares 1