Colchicine Should Not Be Given Three Times Daily (TID) for Gout
Colchicine should never be dosed three times daily for acute gout treatment, as this outdated high-dose regimen provides no additional benefit over low-dose therapy while dramatically increasing gastrointestinal toxicity. 1, 2
Evidence-Based Dosing for Acute Gout Flares
The current standard of care is a low-dose regimen that has replaced older, more toxic protocols:
Administer 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 until the attack resolves. 1, 3
This low-dose approach is as effective as the older high-dose regimen (4.8 mg over 6 hours) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat (NNT) of 5. 1, 2
The safety profile of low-dose colchicine is indistinguishable from placebo, whereas high-dose regimens cause diarrhea in 77% of patients (21-fold increased risk) and vomiting in 17%. 2
Why TID Dosing Is Obsolete and Dangerous
The older regimen of 0.5-0.6 mg every 2 hours until relief or toxicity (which could result in TID or more frequent dosing) is explicitly obsolete and causes severe diarrhea in most patients. 1
All patients receiving the older high-dose protocols developed gastrointestinal side effects, with diarrhea occurring before pain relief in most cases. 4
Colchicine has a narrow therapeutic index with no clear distinction between toxic and lethal doses; fatalities have been reported with acute ingestions exceeding 0.5 mg/kg. 5
Critical Timing and Contraindications
Colchicine must be initiated within 36 hours of symptom onset for effectiveness; beyond this window, efficacy significantly decreases. 1, 6
Absolute contraindications include: concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, cyclosporine, ketoconazole) in patients with renal or hepatic impairment. 1, 3
In severe renal impairment (eGFR <30 mL/min), reduce to a single 0.6 mg dose with no repeat for at least two weeks. 1, 3
Prophylaxis Dosing (Not Acute Treatment)
For gout flare prophylaxis during urate-lowering therapy initiation, the dose is 0.6 mg once or twice daily—never three times daily. 1, 7
Continue prophylaxis for at least 6 months, or 3 months after achieving target serum urate if no tophi are present. 1
Common Pitfalls to Avoid
Never use TID dosing or the obsolete "dose until diarrhea" approach, as this dramatically increases toxicity without improving efficacy. 1, 2, 4
Do not treat patients already receiving prophylactic colchicine with additional colchicine for acute flares if they are on CYP3A4 inhibitors. 3
Failing to screen for drug interactions (particularly with clarithromycin, erythromycin, cyclosporine, or grapefruit juice) can lead to fatal colchicine toxicity. 1, 5
Do not repeat treatment courses more frequently than every 3 days in patients with normal renal function, or every 2 weeks in those with severe renal impairment or on dialysis. 3