What is the recommended dose of colchicine (Colchicine) for acute gout?

Colchicine Dosing for Acute Gout

For acute gout, administer colchicine 1.2 mg at the first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour), but only if treatment can be started within 36 hours of symptom onset. 1, 2, 3, 4

Standard Dosing Regimen

The FDA-approved and guideline-recommended approach is straightforward:

• Loading dose: 1.2 mg (two tablets) at first sign of flare 4
• Second dose: 0.6 mg (one tablet) one hour later 4
• Total dose: 1.8 mg over one hour 1, 2, 3
• Maximum dose: Do not exceed 1.8 mg in one hour period 4

This low-dose regimen is as effective as higher doses but with significantly fewer gastrointestinal side effects (diarrhea, nausea, vomiting). 1, 2, 3, 5, 6

Critical Timing Window

Colchicine must be initiated within 36 hours of symptom onset to be effective. 1, 2, 3 Beyond this timeframe, effectiveness significantly decreases and alternative treatments should be considered. 1 The earlier treatment begins within this window, the better the response. 2, 5

Continuation After Initial Treatment

After the initial 1.8 mg dose over one hour:

• Wait 12 hours before resuming any prophylactic colchicine dosing 4
• Then continue with 0.6 mg once or twice daily until the gout attack completely resolves 1, 2, 3

Dose Adjustments for Renal Impairment

Renal function critically determines safe colchicine dosing:

• eGFR ≥30 mL/min: Use standard dosing (1.2 mg followed by 0.6 mg one hour later) 1
• eGFR <30 mL/min (severe renal impairment): Reduce to single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 2, 3
• Dialysis patients: Single dose of 0.6 mg only, do not repeat before two weeks 1

For patients with severe renal impairment (eGFR <30 mL/min), glucocorticoids are preferred over colchicine as first-line treatment. 1 Consider oral prednisone 30-35 mg/day for 3-5 days or intra-articular corticosteroid injection for single joint involvement. 1

Critical Drug Interactions

Colchicine is absolutely contraindicated with strong P-glycoprotein and/or CYP3A4 inhibitors, especially in patients with renal impairment. 1, 2

Avoid concurrent use with:

• Clarithromycin and erythromycin 1, 2, 3
• Cyclosporine 1, 2, 3
• Ketoconazole and itraconazole 1
• Verapamil and diltiazem 1
• Ritonavir/nirmatrelvir (Paxlovid) 1

Dose reduction is required with moderate CYP3A4/P-glycoprotein inhibitors. 1, 3, 4

Alternative Treatments When Colchicine Cannot Be Used

When colchicine is contraindicated or ineffective:

• NSAIDs: Full FDA-approved doses until complete resolution 1
• Oral corticosteroids: Prednisone 0.5 mg/kg/day (or 30-35 mg/day) for 5-10 days, then stopped or tapered over 7-10 days 1
• Intra-articular corticosteroids: For involvement of 1-2 large joints (dose varies by joint size) 1

Common Pitfalls to Avoid

• Starting treatment beyond 36 hours of symptom onset renders colchicine significantly less effective 1, 2, 3
• Using high-dose regimens (>1.8 mg) increases adverse events without improving efficacy 1, 2, 6
• Failing to check renal function before prescribing can lead to severe toxicity 1
• Not screening for drug interactions with CYP3A4/P-glycoprotein inhibitors risks life-threatening colchicine toxicity 1, 2
• Repeating doses too soon after initial treatment increases toxicity risk without benefit 4

Evidence Quality

The recommendation is based on high-quality guideline evidence from the American College of Rheumatology and European League Against Rheumatism, supported by FDA labeling. 1, 2, 3, 4 A Cochrane systematic review confirms low-dose colchicine (1.8 mg total) provides similar pain reduction to high-dose regimens with significantly fewer adverse events (NNTB of 4-5 for pain relief, NNTH of 2 for high-dose adverse events). 6