Can Uric Acid Lowering Therapy (ULT) and colchicine be taken at the same time?

Can ULT and Colchicine Be Taken at the Same Time?

Yes, urate-lowering therapy (ULT) and colchicine should be taken together—in fact, initiating colchicine prophylaxis with or just prior to starting ULT is strongly recommended to prevent acute gout flares during the first 3-6 months of treatment. 1

Why Concurrent Use is Recommended

• Flare prevention is essential: When ULT is initiated, mobilization of urate from tissue deposits causes changing serum uric acid levels, which paradoxically increases the risk of acute gout flares during the initial treatment phase 1, 2, 3
• Strong guideline support: The 2020 American College of Rheumatology strongly recommends initiating concomitant anti-inflammatory prophylaxis therapy (colchicine, NSAIDs, or prednisone/prednisolone) over no prophylaxis when starting any ULT 1
• European consensus: The 2016 EULAR guidelines recommend prophylaxis during the first 6 months of ULT, with colchicine 0.5-1 mg/day as the recommended prophylactic treatment 1

Dosing Strategy

For ULT (Allopurinol):

• Start low and titrate: Begin allopurinol at 100 mg/day and increase by 100 mg increments every 2-4 weeks until serum uric acid target <6 mg/dL is achieved 1, 4
• Continue during flares: If ULT is indicated while experiencing a gout flare, conditionally recommend starting ULT during the flare rather than waiting for resolution 1

For Colchicine Prophylaxis:

• Prophylactic dose: 0.5-1 mg/day (0.6 mg once or twice daily in US) 1, 5
• Timing: Initiate with or just prior to starting ULT 1
• Duration: Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi present 1

If Acute Flare Occurs During Prophylaxis:

• Treatment dose allowed: Colchicine may be administered for treatment of a gout flare during prophylaxis at doses not to exceed 1.2 mg (two tablets) at first sign followed by 0.6 mg (one tablet) one hour later 5
• Resume prophylaxis: Wait 12 hours, then resume the prophylactic dose 5

Critical Safety Considerations

Dose Adjustments Required:

• Renal impairment: Colchicine dose must be reduced in patients with chronic kidney disease 1, 5
• Severe renal impairment: Colchicine should be avoided entirely 1

Drug Interactions to Avoid:

• Absolute contraindications: Do not co-prescribe colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors such as cyclosporin or clarithromycin 1, 5
• Dose reduction needed: With moderate CYP3A4 inhibitors (diltiazem, verapamil, erythromycin), reduce colchicine to 0.3 mg twice daily or 0.6 mg once daily for prophylaxis 5

Toxicity Monitoring:

• Statin interaction: Patients on concurrent statin therapy should be monitored for potential neurotoxicity and/or muscular toxicity with prophylactic colchicine 1, 6
• Common adverse events: Diarrhoea is the most frequent side effect, occurring more commonly in patients with multiple comorbidities 6

Evidence Supporting Concurrent Use

• Reduced flare frequency: Prophylaxis for up to 6 months during ULT initiation provides greater benefit than 8 weeks of prophylaxis, with flare rates remaining consistently low (3-5%) compared to sharp increases (up to 40%) when prophylaxis ends at 8 weeks 3
• Real-world effectiveness: Patients treated with colchicine prophylaxis during febuxostat initiation suffered significantly fewer total flares (0.30 vs 2.47, p<0.001) and less severe flares than those without prophylaxis 7
• Safety profile: Both colchicine and low-dose steroids were well tolerated for 6 months of prophylaxis, with no increase in adverse events with longer duration 3, 7

Common Pitfalls to Avoid

• Stopping prophylaxis too early: Discontinuing colchicine before 3-6 months leads to increased flare rates 1, 3
• Not adjusting for renal function: Failure to reduce colchicine dose in chronic kidney disease increases toxicity risk 1, 5
• Ignoring drug interactions: Prescribing colchicine with strong CYP3A4/P-gp inhibitors can cause fatal colchicine toxicity 1, 5
• Using colchicine alone long-term: Colchicine treats and prevents flares but does not address underlying hyperuricemia—ULT is essential for disease modification 8