What is the recommended dose of colchicine (Colcrys) 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), then continue 0.6 mg once or twice daily (beginning 12 hours after initial doses) until the attack resolves. 1, 2, 3

Critical Timing Window

• Colchicine must be initiated within 36 hours of symptom onset to be effective; effectiveness significantly decreases beyond this timeframe 1, 2
• Ideally, treatment should begin within 12 hours of symptom onset for maximum benefit 2, 4
• Consider a "pill in the pocket" approach for fully informed patients to self-medicate at the first warning symptoms 4

Evidence Supporting Low-Dose Regimen

• Low-dose colchicine (1.8 mg total over 1 hour) is as effective as high-dose regimens (4.8 mg) with significantly fewer gastrointestinal side effects 1, 2, 4
• The AGREE trial demonstrated equal efficacy for pain reduction at 24 hours with a number needed to treat (NNT) of 5 for achieving 50% or greater pain reduction 4
• High-dose regimens provide no additional benefit but substantially increase gastrointestinal toxicity 4
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 4

Continuation Dosing

• After the initial loading doses (1.2 mg + 0.6 mg), wait 12 hours, then resume prophylactic dosing of 0.6 mg once or twice daily until the gout attack resolves 1, 2
• If a flare occurs during prophylaxis, administer the acute treatment regimen (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the prophylactic dose 3

Absolute Contraindications and Critical Dose Adjustments

Severe Renal Impairment

• Avoid colchicine in patients with eGFR <30 mL/min 1, 2, 4
• If used in moderate renal impairment, reduce to a single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 2
• For dialysis patients, administer a single 0.6 mg dose and do not repeat before two weeks 1

Drug Interactions

• Colchicine is absolutely contraindicated with concurrent use of strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporine, clarithromycin, erythromycin, ketoconazole, itraconazole, verapamil, diltiazem, ritonavir/nirmatrelvir) in patients with renal or hepatic impairment 1, 2, 4, 3
• Screen for these drug interactions before prescribing colchicine 1
• Dose reduction is required with concomitant use of moderate to high potency inhibitors of CYP3A4 and P-glycoprotein 1, 3

Alternative Treatment Options When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution of the crisis 1, 4
• Oral corticosteroids: prednisone 30-35 mg/day (or 0.5 mg/kg/day) for 3-5 days, then stopped or tapered over 7-10 days 1, 2, 4
• Intra-articular corticosteroid injection for involvement of 1-2 large joints or monoarticular gout 1, 4
• For patients with severe renal impairment (eGFR <30 mL/min), glucocorticoids are the preferred first-line treatment over colchicine 1

Common Pitfalls to Avoid

• Failing to start colchicine within 36 hours of symptom onset significantly reduces its effectiveness 2, 4
• Not adjusting colchicine dose in patients with renal impairment or those on interacting medications can lead to life-threatening toxicity 2
• Using high-dose regimens (>1.8 mg in first hour) provides no additional benefit but substantially increases gastrointestinal toxicity 4
• Not screening for drug interactions before prescribing, particularly CYP3A4 and P-glycoprotein inhibitors 1