How is colchicine prescribed for acute gout?

Colchicine Dosing for Acute Gout

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

Critical Timing Window

• Treatment must be initiated within 36 hours of symptom onset - effectiveness drops significantly beyond this timeframe, making colchicine inappropriate for delayed presentations 1, 2, 3
• The American College of Rheumatology emphasizes early treatment, ideally within 12 hours, with a "pill in the pocket" approach for informed patients to self-medicate at first warning symptoms 4

FDA-Approved Dosing Regimen

Acute Treatment:

• 1.2 mg (two 0.6 mg tablets) immediately at flare onset 3
• Followed by 0.6 mg (one tablet) exactly one hour later 3
• Total loading dose: 1.8 mg over one hour 1, 2, 3

Continuation Phase:

• After the initial 1.8 mg loading dose, wait 12 hours, then resume 0.6 mg once or twice daily until the attack completely resolves 1, 2, 3
• This typically takes a few days 1

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat of 5 4
• High-dose regimens provide no additional benefit but substantially increase gastrointestinal toxicity - the older regimen of 0.5-0.6 mg every 2 hours until relief or diarrhea is obsolete and causes severe diarrhea in most patients 4
• All patients in older high-dose studies experienced gastrointestinal side effects (diarrhea and/or vomiting), with a number needed to harm of 1 5

Absolute Contraindications

Do not prescribe colchicine if:

• Patient is taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, ritonavir, atazanavir) or P-glycoprotein inhibitors (cyclosporine) 4, 1, 3
• Severe renal impairment (GFR <30 mL/min) combined with use of these inhibitors 4, 1

Dose Adjustments for Renal Impairment

• Severe renal impairment (GFR <30 mL/min): Reduce to single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 2
• Dialysis patients: Single dose of 0.6 mg only, not to be repeated before two weeks 2

Dose Adjustments for Drug Interactions

When strong CYP3A4 or P-glycoprotein inhibitors cannot be avoided:

• Acute treatment: 0.6 mg × 1 dose, followed by 0.3 mg one hour later (instead of standard 1.2 mg + 0.6 mg) 3
• Do not repeat for at least 3 days 3
• Moderate inhibitors also require dose reduction 1, 2

Combination Therapy Considerations

• The American College of Rheumatology recommends combination therapy with colchicine and NSAIDs for severe attacks involving multiple large joints or polyarticular arthritis 4
• After initial combination treatment, continue prophylactic colchicine (0.6 mg once or twice daily) until the acute attack resolves 4

Alternative Options When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 4, 2
• Oral corticosteroids: Prednisone 0.5 mg/kg/day (or prednisolone 30-35 mg/day) for 3-10 days, then stopped or tapered 4, 2
• Intra-articular corticosteroid injection for involvement of 1-2 large joints 2

Common Pitfalls to Avoid

• Never use the obsolete high-dose regimen (repeated doses every 2 hours) - this causes severe diarrhea without additional benefit 4
• Do not delay treatment beyond 36 hours - colchicine becomes significantly less effective 1, 2
• Always screen for drug interactions before prescribing, particularly CYP3A4 and P-glycoprotein inhibitors 4, 1, 3
• Diarrhea is the first symptom of colchicine poisoning - instruct patients to reduce or stop dosing if this occurs 6
• The maximum dose for acute treatment is 1.8 mg over one hour - higher doses are not more effective 3