What is the recommended dose of colchicine (Colchicine) for treating pseudogout?

Colchicine for Pseudogout

Direct Recommendation

For pseudogout prophylaxis, use colchicine 0.6 mg twice daily, which reduces attack frequency by approximately 70% based on the only available controlled trial. 1

Evidence Base and Treatment Approach

Acute Pseudogout Treatment

While the guidelines provided focus primarily on gout, colchicine's mechanism of action (inhibiting microtubule polymerization and neutrophil migration) is equally applicable to calcium pyrophosphate deposition disease (pseudogout). 2

For acute pseudogout attacks, use the same low-dose regimen as for gout:

• 1.2 mg at first sign of symptoms, followed by 0.6 mg one hour later (total 1.8 mg over one hour) 2, 3
• Continue 0.6 mg once or twice daily until the attack resolves 2, 3
• Treatment must be initiated within 36 hours of symptom onset for maximum effectiveness 3

This low-dose approach provides equal efficacy to high-dose regimens with significantly fewer gastrointestinal side effects. 2, 4, 5

Prophylactic Therapy

The landmark 1986 study specifically examining pseudogout demonstrated that colchicine 0.6 mg twice daily reduced attack frequency from 3.2 episodes per patient per year to 1.0 episode per patient per year (p<0.001), with 90% of patients benefiting. 1

Prophylactic dosing: 0.6 mg once or twice daily 2, 3, 1

Critical Contraindications and Dose Adjustments

Renal Impairment

• Avoid colchicine entirely if eGFR <30 mL/min 3, 6
• If eGFR <30 mL/min and colchicine is absolutely necessary: limit to 0.6 mg as a single dose, no repeat for at least 2 weeks 3
• For dialysis patients: 0.3 mg twice weekly maximum for prophylaxis 6

Drug Interactions - Absolute Contraindications

Never combine colchicine with strong CYP3A4 or P-glycoprotein inhibitors in patients with any renal or hepatic impairment. 2, 3, 6 These include:

• Clarithromycin, erythromycin 2, 3
• Cyclosporine 2, 3
• Ketoconazole, itraconazole 3
• Ritonavir/nirmatrelvir (Paxlovid) 3

Alternative Options When Colchicine is Contraindicated

First-line alternatives:

• Oral corticosteroids: prednisone 30-35 mg daily for 3-5 days 2, 3, 6
• Intra-articular corticosteroid injection for monoarticular involvement 3, 6
• NSAIDs at full FDA-approved doses (naproxen, indomethacin, sulindac) until complete resolution 2, 3

Use NSAIDs cautiously in patients with renal disease, heart failure, or cirrhosis. 2

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens (>1.8 mg in first hour) - they provide no additional benefit but substantially increase gastrointestinal toxicity 2, 6
• Never delay treatment beyond 36 hours - effectiveness drops significantly 2, 3
• Never use the obsolete regimen of 0.5 mg every 2 hours until relief or toxicity - this causes severe diarrhea in most patients 2
• Always calculate eGFR before prescribing and screen for CYP3A4/P-glycoprotein inhibitor interactions 3, 6

Monitoring Requirements

Monitor for signs of toxicity, particularly:

• Creatinine phosphokinase (CPK) levels 6
• Gastrointestinal symptoms 6
• Neuromuscular toxicity 6
• Renal function before initiation and periodically during treatment 6