What is the recommended dose of colchicine (Colcrys) for an acute gout attack?

Colchicine Dosing for Acute Gout Attack

For an acute gout attack, administer colchicine 1.2 mg (two tablets) at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later, for a total of 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 to be effective; delaying beyond this window significantly reduces efficacy 1, 2
• The "pill in the pocket" approach allows fully informed patients to self-medicate at the first warning symptoms, ideally within 12 hours of onset for maximum effectiveness 1

Continuation Dosing After Initial Treatment

• After the loading doses (1.2 mg + 0.6 mg), wait 12 hours, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves, typically within a few days 1, 2, 3
• If a gout flare occurs while already on prophylactic colchicine, you may administer the acute treatment regimen (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the prophylactic dose 3

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that this low-dose regimen (1.8 mg total) is equally effective as the older high-dose regimen (4.8 mg over 6 hours) for achieving 50% or greater pain reduction at 24 hours, with a number needed to treat of 5 1
• Critically, the low-dose regimen causes significantly fewer gastrointestinal adverse events compared to high-dose colchicine 1, 4
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 1

Absolute Contraindications

• Do not use colchicine in patients taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole) or P-glycoprotein inhibitors (cyclosporine) - this is an absolute contraindication 1, 2
• Avoid in severe renal impairment (GFR <30 mL/min); if absolutely necessary, reduce to a single 0.6 mg dose with no repeat treatment for at least two weeks 1, 2
• Patients with both renal or hepatic impairment AND taking potent CYP3A4 or P-glycoprotein inhibitors should not receive colchicine 1

Dose Adjustments for Drug Interactions

• For moderate CYP3A4 or P-glycoprotein inhibitors, dose reduction is required 2, 3
• Grapefruit juice can increase colchicine concentrations and should be avoided 5
• Concomitant statin use may increase risk of myopathy 5

Common Pitfalls to Avoid

• Never exceed 1.8 mg in the first hour - higher doses provide no additional benefit but substantially increase gastrointestinal toxicity 1, 3
• The maximum recommended dose for treatment of a gout flare is 1.8 mg over one hour 3
• Do not use colchicine as an analgesic for pain from other causes 3

Alternative Options if Colchicine Contraindicated

• Use full FDA-approved doses of NSAIDs (naproxen, indomethacin, or sulindac) until the attack completely resolves 1
• Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days) are effective alternatives 1
• For severe attacks involving multiple large joints, combination therapy with colchicine and NSAIDs provides synergistic anti-inflammatory effects 1