What is the recommended dose of Colchicine (colchicine) for acute and chronic 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 Requirements

• Colchicine must be initiated within 36 hours of symptom onset to be effective; efficacy significantly decreases beyond this timeframe 1, 2
• The "pill in the pocket" approach is recommended for fully informed patients to self-medicate at the first warning symptoms 4
• Treatment delayed beyond 36 hours substantially reduces effectiveness 2

Evidence Supporting Low-Dose Regimen

• The low-dose regimen (1.8 mg total) is as effective as high-dose colchicine (4.8 mg) for achieving 50% or greater pain reduction at 24 hours, with a number needed to treat of 5 4, 5, 6
• High-dose regimens provide no additional benefit but substantially increase gastrointestinal toxicity 4, 7
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 4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 (Chronic Gout Management)

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

Duration of Prophylaxis

• Initiate prophylaxis with or just prior to starting urate-lowering therapy 1, 2
• Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi are present 1, 2
• If tophi are present, continue for 6 months after achieving target serum urate 1, 2

Dose Adjustments for Renal Impairment

Moderate Renal Impairment (eGFR ≥30 mL/min)

• Use standard low-dose regimen (1.2 mg followed by 0.6 mg one hour later) for acute flares 1
• Treatment must be initiated within 12-36 hours of symptom onset 1

Severe Renal Impairment (eGFR <30 mL/min)

• Reduce to a single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 2
• Glucocorticoids are preferred as first-line treatment over colchicine in this population 1
• Colchicine should be avoided in severe renal impairment 1, 4

Dialysis Patients

• Administer a single dose of 0.6 mg and do not repeat before two weeks 1

Critical Drug Interactions Requiring Dose Adjustment

Absolute Contraindications

Do not use colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors, especially in patients with renal or hepatic impairment. 1, 4, 3

These include:

• Clarithromycin, erythromycin 1, 2, 3
• Cyclosporine 1, 2, 3
• Ketoconazole, itraconazole 1, 3
• Ritonavir-containing regimens (including Paxlovid) 1, 3
• Verapamil, diltiazem 1

Dose Adjustments with Moderate CYP3A4/P-gp Inhibitors

When strong inhibitors cannot be avoided and renal/hepatic function is normal 3:

• For acute flares: Reduce to 0.6 mg × 1 dose, followed by 0.3 mg one hour later; do not repeat for at least 3 days 3
• For prophylaxis: Reduce to 0.3 mg once daily 3
• For chronic FMF: Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice daily) 3

Alternative Treatments When Colchicine is Contraindicated

First-Line Alternatives

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

Combination Therapy

• For severe attacks involving multiple large joints or polyarticular arthritis, combination therapy with colchicine and NSAIDs is appropriate 4
• This provides synergistic anti-inflammatory effects targeting different pathways 4
• Be cautious of synergistic gastrointestinal toxicity when combining NSAIDs with systemic corticosteroids 4

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens (>1.8 mg in first hour) as they provide no additional benefit but substantially increase toxicity 4, 7
• Always screen for drug interactions with CYP3A4/P-glycoprotein inhibitors before prescribing 1
• Calculate eGFR immediately when considering colchicine for acute gout 1
• Do not delay treatment beyond 36 hours of symptom onset 1, 2
• Colchicine is not an analgesic and should not be used to treat pain from other causes 3