What is the recommended dosage of colchicine (Colchicine) for acute gout attacks and other conditions?

Colchicine Dosage Recommendations

For acute gout attacks, administer colchicine 1.2 mg at the first sign of flare followed by 0.6 mg one hour later (total 1.8 mg), but only if started within 36 hours of symptom onset; for prophylaxis, use 0.6 mg once or twice daily. 1, 2, 3

Acute Gout Treatment

The low-dose regimen (1.8 mg total over 1 hour) is as effective as higher doses with significantly fewer gastrointestinal side effects. 1, 2, 4

Standard Dosing Protocol

• Loading dose: 1.2 mg (two tablets) at first sign of gout flare 1, 3
• Second dose: 0.6 mg (one tablet) exactly one hour later 1, 3
• Maximum total dose: 1.8 mg over one hour period 1, 3
• After initial treatment: Resume prophylactic dosing of 0.6 mg once or twice daily beginning 12 hours after the initial doses, continuing until the attack resolves 1, 4

Critical Timing Window

• Colchicine must be started within 36 hours of symptom onset for effectiveness 1, 2, 4
• Ideally initiate within 12-36 hours of flare onset for maximum benefit 2
• Effectiveness significantly decreases beyond the 36-hour window 1, 4

Prophylaxis Dosing

For preventing gout flares, the recommended dose is 0.6 mg once or twice daily (maximum 1.2 mg/day). 1, 2, 3

When to Initiate Prophylaxis

• Start with or just prior to beginning urate-lowering therapy (allopurinol, febuxostat, pegloticase) 1, 4, 3
• An increase in gout flares commonly occurs after initiating urate-lowering therapy due to mobilization of urate from tissue deposits 3

Duration of Prophylaxis

• Minimum duration: 6 months 1, 2
• If no tophi present: Continue for 3 months after achieving target serum urate 1, 4
• If tophi present: Continue for 6 months after achieving target serum urate 1, 4

Dose Adjustments for Renal Impairment

Patients with severe renal impairment require significant dose reduction to prevent life-threatening toxicity. 1, 4

• Severe renal impairment: Single dose of 0.6 mg only, with no repeat treatment for at least 2 weeks 1, 4
• Dialysis patients: Single dose of 0.6 mg, not to be repeated before 2 weeks 1
• Moderate renal impairment: Reduce dose to 0.6 mg with no repeat for at least 2 weeks 2

Critical Drug Interactions Requiring Dose Reduction

Concomitant use of CYP3A4 and P-glycoprotein inhibitors dramatically increases colchicine levels and toxicity risk. 1, 4, 5

Major Interacting Medications

• Strong inhibitors (AVOID or use extreme caution): Clarithromycin, erythromycin, cyclosporine, ketoconazole 1, 4, 5
• Other significant interactions: Disulfiram, statins (increased myopathy risk), grapefruit juice 4, 5
• Dose reduction required with moderate to high potency CYP3A4 and P-glycoprotein inhibitors 1, 4
• If patients have taken these drugs within the prior 14 days, dose adjustments are necessary 3

Familial Mediterranean Fever (FMF) Dosing

For FMF in adults, the recommended dose is 1.2 to 2.4 mg daily, administered in one to two divided doses. 3

Pediatric FMF Dosing

• Ages 4-6 years: 0.3 to 1.8 mg daily 3
• Ages 6-12 years: 0.9 to 1.8 mg daily 3
• Adolescents >12 years: 1.2 to 2.4 mg daily 3
• Doses may be given as single or divided dose twice daily 3
• Increase in 0.3 mg/day increments as needed to control disease and as tolerated 3

Common Pitfalls to Avoid

• Never use colchicine beyond 36 hours of symptom onset - effectiveness is significantly reduced 1, 2, 4
• Do not use high-dose regimens - the low-dose protocol (1.8 mg total) is equally effective with far fewer side effects 1, 2, 4
• Always adjust doses in renal impairment - failure to do so can result in fatal toxicity with multi-organ failure 1, 2, 5
• Screen for drug interactions before prescribing - CYP3A4/P-gp inhibitors can cause life-threatening colchicine accumulation 1, 4, 5
• Do not use colchicine as an analgesic - it is not effective for pain from other causes 3
• Recognize toxicity early - colchicine poisoning presents with gastroenteritis, hypotension, lactic acidosis, and can progress to multi-organ failure 5

Alternatives When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses until complete resolution 1
• Corticosteroids: Prednisone 0.5 mg/kg/day for 5-10 days, then stopped or tapered over 7-10 days 1
• Intra-articular corticosteroid injections for involvement of 1-2 large joints (dose varies by joint size) 1