What is the recommended dosage of colchicine (Colcrys) for acute gouty arthritis?

Colchicine Dosing for Acute Gouty Arthritis

For acute gout flares, administer colchicine 1.2 mg at the first sign of attack, followed by 0.6 mg one hour later (total 1.8 mg), but only if treatment can be initiated within 36 hours of symptom onset. 1, 2, 3

Treatment Algorithm for Acute Gout

Timing is Critical

• Colchicine must be started within 36 hours of symptom onset to be effective 1, 2, 4
• Initiate pharmacologic treatment within 24 hours of acute gout attack onset for optimal outcomes 1
• Effectiveness significantly decreases beyond the 36-hour window 2, 4

Standard Dosing Regimen (Normal Renal Function)

• Initial dose: 1.2 mg (two tablets) at first sign of flare 1, 3
• Second dose: 0.6 mg (one tablet) one hour later 1, 3
• Total maximum dose: 1.8 mg over one hour period 3
• Higher doses have not been found to be more effective and cause significantly more gastrointestinal side effects 2, 4, 5

Post-Acute Dosing

• After the initial 1.8 mg loading doses, wait 12 hours, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack resolves 1, 2, 3
• Continue this prophylactic dose throughout the acute flare resolution 1, 2

Special Populations and Dose Adjustments

Patients Already on Prophylactic Colchicine

• If already taking prophylactic colchicine, choose alternative therapy (NSAID or corticosteroid) rather than additional colchicine 1
• This prevents excessive colchicine exposure and toxicity 1

Severe Renal Impairment (eGFR <30 mL/min)

• Reduce to single dose of 0.6 mg with no repeat treatment for at least two weeks 2, 4, 6
• For dialysis patients: single 0.6 mg dose, not repeated before two weeks 2, 6
• Consider glucocorticoids as preferred first-line treatment instead in severe renal impairment 2

Drug Interactions Requiring Dose Reduction

• Absolutely contraindicated with strong P-glycoprotein and/or CYP3A4 inhibitors in patients with renal impairment 2
• Major interactions requiring dose adjustment include: clarithromycin, erythromycin, cyclosporine, ketoconazole, itraconazole, verapamil, diltiazem, and ritonavir/nirmatrelvir (Paxlovid) 2, 4, 6
• Screen for these interactions before prescribing 2

Alternative Therapies When Colchicine is Contraindicated

NSAIDs

• Full FDA-approved doses until complete resolution of the gout attack 1, 6
• Naproxen, indomethacin, and sulindac are FDA-approved for acute gout 1
• Continue at full dose until the gouty attack has completely resolved 1

Corticosteroids

• Oral prednisone 0.5 mg/kg/day for 5-10 days, then stop or taper over 7-10 days 1, 6
• Intra-articular corticosteroids for involvement of 1-2 large joints (dose varies by joint size) 1, 6
• Intramuscular triamcinolone acetonide 60 mg followed by oral prednisone 1

Common Pitfalls to Avoid

Dosing Errors

• Do not use high-dose colchicine regimens (the old regimen of repeated hourly doses) - these cause severe gastrointestinal toxicity without improved efficacy 2, 4, 5
• The number needed to harm with colchicine is 1 for gastrointestinal side effects (all patients in older high-dose studies experienced diarrhea and/or vomiting) 5

Timing Mistakes

• Do not initiate colchicine beyond 36 hours of symptom onset - it will be ineffective 1, 2, 4
• Do not interrupt ongoing urate-lowering therapy during an acute attack 1

Combination Therapy Considerations

• For severe polyarticular gout, combination therapy is appropriate: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids with other modalities 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Prophylaxis Dosing (Separate from Acute Treatment)

• 0.6 mg once or twice daily for prophylaxis when initiating urate-lowering therapy 1, 4
• Continue for at least 6 months, or 3 months after achieving target serum urate (no tophi), or 6 months after achieving target (if tophi present) 1, 4, 6