Is colchicine (colchicine) and allopurinol (allopurinol) used together a usual treatment for gout?

Colchicine and Allopurinol Together: Standard Gout Management

Yes, using colchicine and allopurinol together is the usual and recommended treatment approach for gout—specifically, colchicine serves as prophylaxis against acute flares when initiating allopurinol therapy for long-term urate lowering. 1, 2

The Two-Drug Strategy

This combination addresses two distinct therapeutic goals simultaneously:

• Allopurinol lowers serum uric acid levels long-term to prevent future gout attacks and reduce urate crystal deposits 2
• Colchicine prevents the paradoxical increase in acute gout flares that occurs when starting urate-lowering therapy 3

Why Prophylaxis Is Essential

Starting allopurinol without colchicine prophylaxis significantly increases the risk of acute gout attacks. The rapid reduction in serum uric acid mobilizes urate from tissue deposits, triggering inflammatory flares. 2, 4

Evidence for Combined Use

• High-strength evidence demonstrates that prophylactic colchicine reduces acute gout attacks by at least 50% when initiating urate-lowering therapy 3
• In a placebo-controlled trial of 43 patients starting allopurinol, only 33% of colchicine-treated patients experienced flares versus 77% receiving placebo (NNT = 2) 5
• The EULAR guidelines give this combination a strength of recommendation of 90 (95% CI: 86-95) 3

Dosing Protocol

Colchicine Prophylaxis

• Standard dose: 0.5-1 mg daily 3, 1
• FDA-approved dose: 0.6 mg once or twice daily (maximum 1.2 mg/day for prophylaxis) 4
• Low-dose is equally effective: 0.6 mg/day prevents flares as effectively as 1.2 mg/day but with fewer adverse events (particularly diarrhea) 6

Allopurinol Initiation

• Start low: 100 mg daily 1, 2
• Titrate gradually: Increase by 100 mg every 2-4 weeks until serum urate <6 mg/dL (360 μmol/L) 1, 2
• Maximum dose: 800 mg/day 2

Duration of Prophylaxis

Continue colchicine for at least 6 months after starting allopurinol. 1, 4

• Moderate-strength evidence indicates prophylaxis duration should exceed 8 weeks 3
• In clinical trials, acute attacks spiked when prophylaxis was discontinued at 8 weeks, but not when continued for 6 months 3
• The FDA label specifically states colchicine prophylaxis "may be beneficial for at least the first six months of uric acid-lowering therapy" 4

Critical Safety Considerations

Dose Adjustments Required

Reduce colchicine dose in renal impairment to avoid neurotoxicity and other serious adverse events. 3, 1

Avoid or significantly reduce colchicine dose with strong CYP3A4 or P-gp inhibitors (clarithromycin, ketoconazole, ritonavir, etc.)—fatal colchicine toxicity has been reported with these combinations. 4

Common Pitfalls

• Diarrhea is the most common adverse event with colchicine (43% vs 4% with placebo), but occurs less frequently with low-dose regimens 5, 6
• Drug interactions are common—21% of patients starting this combination are already on statins, though statins alone don't significantly increase adverse events 7
• Failure to provide prophylaxis leads to increased acute attacks and reduced medication adherence 1

Monitoring

• Check serum uric acid levels regularly with target <6 mg/dL 1
• Monitor renal function during early allopurinol therapy, as BUN may rise in patients with pre-existing renal disease 2
• Maintain adequate hydration (≥2 liters daily urinary output) to prevent xanthine calculi and urate precipitation 2

Alternative Prophylaxis Options

If colchicine is contraindicated or not tolerated:

• NSAIDs at low doses with gastric protection (though evidence is less convincing than for colchicine—level IIa) 3, 1
• Low-dose corticosteroids (<10 mg/day) if both colchicine and NSAIDs are contraindicated 1