What is the maximum dose of colchicine (Colcrys) for acute gout?

Maximum Dose of Colchicine for Acute Gout

For acute gout flares, the maximum dose is 1.8 mg total over one hour: 1.2 mg at first sign of symptoms followed by 0.6 mg one hour later, with no additional acute dosing permitted. 1

Acute Treatment Dosing

• The FDA-approved regimen is strictly limited to 1.2 mg (two tablets) at the first sign of a gout flare, followed by 0.6 mg (one tablet) one hour later, for a maximum total of 1.8 mg over one hour 1
• Higher doses have not been found to be more effective and significantly increase adverse events 1
• This low-dose regimen is as effective as previously used high-dose regimens but with substantially fewer gastrointestinal side effects 2

Critical Timing Window

• Colchicine must be initiated within 36 hours of symptom onset to be effective 3, 4, 5
• Beyond 36 hours, effectiveness significantly decreases and colchicine should not be used for acute treatment 3, 4, 5
• The "pills in the pocket" approach—taking colchicine at the very first sign of symptoms—maximizes efficacy 6

Continuation After Initial Dosing

• After the initial 1.8 mg dose over one hour, wait 12 hours before resuming any colchicine 1
• If the patient was already on prophylactic colchicine (0.6 mg once or twice daily), resume this prophylactic dose 12 hours after the acute treatment doses 1
• Continuation dosing for the acute flare can be 0.6 mg twice daily (maximum 1.2 mg/day) until the attack resolves, but this should start at least 12 hours after the initial loading doses 2

Prophylaxis Dosing (Different from Acute Treatment)

• For gout flare prophylaxis, the maximum dose is 1.2 mg/day, typically given as 0.6 mg once or twice daily 1
• This prophylactic dosing is maintained long-term (at least 6 months) when initiating urate-lowering therapy 3, 5

Dose Reductions Required

Renal impairment:

• For severe renal impairment (CrCl <30 mL/min) or dialysis patients, acute treatment should be a single 0.6 mg dose only, not repeated for at least two weeks 4, 5
• Creatinine clearance must be calculated before prescribing, especially in elderly patients who may have normal serum creatinine but reduced clearance 3, 4

Drug interactions:

• Colchicine is absolutely contraindicated with strong CYP3A4 and/or P-glycoprotein inhibitors in patients with renal or hepatic impairment 3, 1
• With moderate CYP3A4/P-gp inhibitors (clarithromycin, erythromycin, cyclosporine, azole antifungals, calcium channel blockers), reduce acute treatment to 0.6 mg × 1 dose followed by 0.3 mg one hour later, not repeated for at least 3 days 1

Common Pitfalls to Avoid

• Never use the outdated high-dose regimen (0.5-0.6 mg every 1-2 hours until relief or toxicity)—this causes severe gastrointestinal toxicity without additional benefit 2, 3
• Do not exceed 1.8 mg total in the first hour for acute treatment 1
• Do not repeat acute treatment dosing within 3 days (or 14 days in severe renal impairment) 4, 5, 1
• Do not ignore the 36-hour window—colchicine is ineffective if started later 3, 4, 5
• Always check for drug interactions before prescribing, as colchicine has a narrow therapeutic index and fatal toxicity has been reported with CYP3A4 inhibitors like clarithromycin 1, 7