What is the standard dosing for colchicine (Colcrys) in treating gout?

Standard Dosing for Colchicine in Gout

For acute gout flares, administer 1.2 mg at the first sign of symptoms followed by 0.6 mg one hour later (total 1.8 mg over one hour), and this regimen must be initiated within 36 hours of symptom onset to be effective. 1, 2, 3

Acute Gout Treatment

Initial Dosing Regimen

• Loading dose: 1.2 mg (two tablets) followed by 0.6 mg (one tablet) one hour later for a total of 1.8 mg over one hour 1, 3
• This low-dose regimen is as effective as higher doses but with significantly fewer gastrointestinal side effects 1, 4
• After the initial doses, continue with 0.6 mg once or twice daily (beginning 12 hours after initial doses) until the gout attack resolves 1, 2

Critical Timing Window

• Colchicine must be started within 36 hours of symptom onset—effectiveness significantly decreases beyond this timeframe 1, 2, 5
• Early initiation (ideally within 12-36 hours) maximizes therapeutic benefit 2

Evidence for Low-Dose Superiority

• Low-dose colchicine (1.8 mg total) achieved 37.8% response rate (≥50% pain reduction at 24 hours) compared to 15.5% with placebo 4
• High-dose colchicine (4.8 mg over 6 hours) showed similar efficacy (32.7% response) but caused diarrhea in 76.9% of patients versus only 23% with low-dose 4
• The adverse event profile of low-dose colchicine is indistinguishable from placebo 4

Prophylaxis Dosing

Standard Prophylactic Regimen

• 0.6 mg once or twice daily for prevention of gout flares 1, 3
• Maximum recommended dose is 1.2 mg/day 3

Duration of Prophylaxis

• Continue for at least 6 months when initiating urate-lowering therapy 1, 5
• Alternative approach: 3 months after achieving target serum urate if no tophi present, or 6 months if tophi are detected 1
• Prophylaxis should be initiated with or just prior to starting urate-lowering therapy to prevent mobilization flares 1, 3

Dose Adjustments for Renal Impairment

Severe Renal Impairment (eGFR <30 mL/min)

• Single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 3
• For dialysis patients, administer a single 0.6 mg dose and do not repeat before two weeks 5, 3
• Glucocorticoids are preferred over colchicine in patients with severe renal impairment 1

Moderate Renal Impairment (eGFR 30-60 mL/min)

• Low-dose colchicine (1.2 mg followed by 0.6 mg one hour later) may be used if eGFR ≥30 mL/min 1
• Reduce prophylactic dose to 0.6 mg once daily rather than twice daily 3

Critical Drug Interactions

Absolute Contraindications

• Do not use colchicine with strong CYP3A4 or P-glycoprotein inhibitors including: 1, 3
  • Clarithromycin, erythromycin
  • Ketoconazole, itraconazole
  • Cyclosporine
  • Ritonavir-containing regimens (including Paxlovid)
  • Atazanavir, indinavir, nelfinavir, saquinavir

Dose Reduction Required

• When moderate CYP3A4/P-gp inhibitors cannot be avoided: 3
  • For acute gout: reduce to 0.6 mg × 1 dose, followed by 0.3 mg one hour later; do not repeat for 3 days
  • For prophylaxis: reduce maximum daily dose to 0.6 mg (may give as 0.3 mg twice daily)

Alternative Treatments When Colchicine is Contraindicated

First-Line Alternatives

• NSAIDs at full FDA-approved doses until complete resolution of symptoms 1, 5
• 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, 5
• Intra-articular corticosteroid injection for involvement of 1-2 large joints (dose varies by joint size) 6, 1, 5

Common Pitfalls to Avoid

Dosing Errors

• Never use the old high-dose regimen (1 g loading dose followed by 0.5 mg every 2-3 hours)—this causes severe diarrhea in most patients before pain relief occurs 6, 7
• Do not exceed 1.8 mg total dose in the first hour for acute treatment 3
• Higher doses have not been found to be more effective and significantly increase toxicity 4

Timing Failures

• Starting colchicine beyond 36 hours of symptom onset dramatically reduces effectiveness 1, 2
• Failing to continue prophylaxis for adequate duration (minimum 6 months) leads to recurrent flares 1

Drug Interaction Oversights

• Always screen for CYP3A4/P-gp inhibitors before prescribing colchicine 1, 2
• Fatal colchicine toxicity has been reported with clarithromycin co-administration 3
• Grapefruit juice can increase colchicine concentrations 8

Renal Function Neglect

• Calculate eGFR immediately when considering colchicine for acute gout 1
• Not adjusting dose in renal impairment can lead to life-threatening toxicity with multi-organ failure 8

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