What is the recommended dosage of colchicine (Colchicine) for treating gout?

Colchicine Dosing for Gout

Acute Gout Flare Treatment

For acute gout flares, administer colchicine 1.2 mg at the first sign of symptoms, followed by 0.6 mg one hour later (total 1.8 mg over one hour), then continue 0.6 mg once or twice daily (starting 12 hours after initial doses) until the attack resolves. 1, 2, 3

Critical Timing Considerations

• Colchicine should only be initiated within 36 hours of symptom onset, as effectiveness significantly decreases beyond this timeframe 1, 4, 2
• The European League Against Rheumatism emphasizes that colchicine is most effective when administered within 12 hours of symptom onset, supporting a "pill in the pocket" approach for fully informed patients to self-medicate at the first warning symptoms 4

Evidence Supporting Low-Dose Regimen

• The low-dose regimen (1.8 mg total) is as effective as high-dose colchicine (4.8 mg over 6 hours) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat of 5 4, 5
• High-dose regimens provide no additional benefit but substantially increase gastrointestinal toxicity, with 76.9% of patients experiencing diarrhea compared to 23% with low-dose regimen 4, 5
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 4

Prophylaxis Dosing

For gout flare prophylaxis, the recommended dose is 0.6 mg once or twice daily, with a maximum of 1.2 mg/day. 1, 2, 3

When to Initiate and Duration

• Prophylaxis should be initiated with or just prior to starting urate-lowering therapy (such as allopurinol, febuxostat, or pegloticase) 1, 2, 3
• Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are detected on physical exam, or 6 months after achieving target serum urate if tophi are present 1, 2
• An increase in gout flares may occur after initiation of uric acid-lowering therapy due to mobilization of urate from tissue deposits, making prophylaxis particularly important during this period 3

Dose Adjustments for Renal Impairment

For patients with severe renal impairment (GFR <30 mL/min), reduce the acute treatment dose to a single dose of 0.6 mg with no repeat treatment for at least two weeks. 1, 2

• For patients on dialysis, administer a single dose of 0.6 mg and do not repeat before two weeks 1
• The European League Against Rheumatism advises avoiding colchicine entirely in patients with severe renal impairment 4

Critical Drug Interactions Requiring Dose Adjustment

Colchicine is absolutely contraindicated in patients taking strong CYP3A4 inhibitors (clarithromycin, erythromycin) or P-glycoprotein inhibitors (cyclosporine), especially if they also have renal or hepatic impairment. 1, 4, 2

• Dose reduction is required with concomitant use of moderate to high potency inhibitors of CYP3A4 and P-glycoprotein 1, 2, 3
• Major drug interactions requiring dose adjustment include clarithromycin, erythromycin, cyclosporine, and disulfiram 1, 2
• If patients are taking or have recently completed treatment with these drugs within the prior 14 days, dose adjustments per FDA labeling are mandatory 3

Common Pitfalls to Avoid

• Never delay treatment beyond 36 hours after symptom onset, as this significantly reduces effectiveness 1, 4, 2
• Do not use high-dose regimens (>1.8 mg in first hour), as they provide no additional benefit but substantially increase gastrointestinal toxicity 4, 5
• Colchicine is not an analgesic medication and should not be used to treat pain from other causes 3
• The safety and efficacy of repeat treatment for gout flares has not been fully evaluated, so use caution with frequent repeated courses 3

Alternative Options When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution of the attack 1, 4
• Oral corticosteroids such as prednisone 0.5 mg/kg/day (or prednisolone 30-35 mg/day) for 5-10 days, then stopped or tapered over 7-10 days 1, 4
• Intra-articular corticosteroid injections for involvement of 1-2 large joints 1