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

Colchicine Dosing for Acute Gout Flare

For an acute gout flare, administer colchicine 1.2 mg (two tablets) at the first sign of symptoms, 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 for colchicine to be effective as monotherapy for acute gout 1, 2
• The European League Against Rheumatism emphasizes that colchicine is most effective when administered within 12 hours of symptom onset 2
• Delaying treatment beyond this window significantly reduces effectiveness and may require alternative or combination therapy 2

Evidence Supporting Low-Dose Regimen

The recommended low-dose regimen (1.8 mg total) is based on the landmark AGREE trial, which demonstrated that this dosing is equally effective as the older high-dose regimen (4.8 mg over 6 hours) but with dramatically fewer side effects 2, 4:

• 37.8% of patients achieved ≥50% pain reduction at 24 hours with low-dose colchicine versus 32.7% with high-dose and 15.5% with placebo 4
• The low-dose regimen had a safety profile indistinguishable from placebo, while high-dose colchicine caused diarrhea in 76.9% of patients (versus 23% with low-dose) 4
• No patients on low-dose colchicine experienced severe diarrhea or vomiting, compared to 19.2% and 17.3% respectively with high-dose 4

Continuation Dosing After Initial Treatment

• After the initial 1.8 mg loading dose, continue with 0.6 mg once or twice daily (prophylactic dosing) until the acute attack completely resolves, typically within a few days 1, 2, 3
• If already on prophylactic colchicine when a flare occurs, you may still administer the acute treatment dose (1.2 mg followed by 0.6 mg one hour later), but then wait 12 hours before resuming the prophylactic dose 1, 3
• The maximum recommended dose for treatment of gout flares is 1.8 mg over one hour 3

Absolute Contraindications and Critical Dose Adjustments

Do not use colchicine in patients taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir, atazanavir) as fatal colchicine toxicity has been reported 1, 2, 3:

• For patients on these medications, the acute treatment dose must be reduced to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, and this dose cannot be repeated for at least 3 days 3
• Patients with both renal or hepatic impairment AND taking these inhibitors should not receive colchicine at all 2

Severe renal impairment (GFR <30 mL/min) is a relative contraindication 2:

• However, recent evidence suggests that reduced doses (≤0.5 mg/day) can be used cautiously in severe CKD with close monitoring, showing 77% tolerability and 83% efficacy without serious adverse events 5
• The FDA label requires dose adjustment in moderate to severe CKD 1, 3

Alternative Options When Colchicine is Contraindicated or Ineffective

If colchicine cannot be used or is ineffective:

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, sulindac) until the attack resolves 1, 2
• Oral corticosteroids: prednisone or prednisolone 30-35 mg daily for 3-5 days, or at least 0.5 mg/kg/day for 5-10 days 1, 2
• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement of large joints 1, 2

Common Pitfalls to Avoid

• Never use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or toxicity), which causes severe diarrhea in most patients without additional benefit 2
• Do not exceed 1.8 mg in the first hour as higher doses provide no additional efficacy but substantially increase gastrointestinal toxicity 2, 4
• Always calculate estimated GFR before prescribing, as real-world data shows physicians frequently prescribe excessive doses (mean 2.8 mg in first 24 hours) without accounting for renal impairment 6
• Screen for drug interactions with CYP3A4 and P-glycoprotein inhibitors before every colchicine prescription 1, 2, 3
• Do not delay treatment waiting for definitive diagnosis if gout is clinically suspected, as efficacy drops significantly after 36 hours 1, 2