What is the recommended oral colchicine (Colchicine) dose for acute gouty arthritis?

Oral Colchicine Dosing for Acute Gouty Arthritis

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 until the attack resolves. 1, 2, 3

Acute Treatment Regimen

Initial Loading Dose

• Give 1.2 mg (two tablets) immediately at first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 3
• Total maximum dose in first hour: 1.8 mg 1, 2, 3
• This low-dose regimen is as effective as higher doses (4.8 mg) but with significantly fewer gastrointestinal side effects 1, 4

Continuation Therapy

• After the initial 1.8 mg loading dose, continue with 0.6 mg once or twice daily (beginning 12 hours after initial doses) until the gout attack resolves 1, 4
• If already on prophylactic colchicine, you may still give the loading dose (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the prophylactic dose 3

Critical Timing Considerations

Colchicine should only be initiated within 36 hours of symptom onset 1, 2

• Effectiveness significantly decreases beyond this timeframe 1
• The European League Against Rheumatism recommends starting ideally within 12 hours for maximum effectiveness 2
• Consider a "pill in the pocket" approach for well-informed patients to self-medicate at first warning symptoms 4

Dose Adjustments for Special Populations

Severe Renal Impairment (GFR <30 mL/min/1.73m²)

• Reduce to a single dose of 0.6 mg with no repeat treatment for at least two weeks 1
• For dialysis patients, give single 0.6 mg dose and do not repeat before two weeks 1

Drug Interactions Requiring Dose Reduction

• Absolute contraindication: Do not use colchicine with strong CYP3A4 inhibitors (clarithromycin, erythromycin) or P-glycoprotein inhibitors (cyclosporine), especially in patients with renal or hepatic impairment 1, 2, 4, 3
• Moderate inhibitors require dose reduction per FDA labeling 1, 3

Common Pitfalls to Avoid

• Do not use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or toxicity) - this causes severe diarrhea in most patients with no additional benefit 4
• Do not exceed 1.8 mg in the first hour - higher doses provide no additional efficacy but substantially increase gastrointestinal toxicity 1, 4
• Do not start colchicine beyond 36 hours after symptom onset - effectiveness is significantly reduced 1, 2
• All patients treated with standard dosing will experience some gastrointestinal side effects, but these are significantly less severe with the low-dose regimen compared to historical high-dose protocols 5

Alternative Options When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 1, 4
• Oral corticosteroids: 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