Colchicine Dosing for Acute Gout Flare
For an acute gout flare, administer colchicine 1.2 mg (two tablets) at the first sign of symptoms, followed by 0.6 mg (one tablet) one hour later, for a total of 1.8 mg over one hour. 1, 2
Optimal Timing and Administration
Treatment must be initiated within 12 hours of symptom onset for maximum effectiveness - efficacy drops significantly if delayed beyond 36 hours from flare onset. 3, 2
After the initial 1.8 mg loading dose, continue with 0.6 mg once or twice daily until the acute attack resolves, typically within a few days. 2, 1
The "pill in the pocket" approach is recommended - fully informed patients should self-medicate at the first warning symptoms without waiting for medical consultation. 3, 2
Evidence Supporting Low-Dose Regimen
The low-dose regimen (1.8 mg total) is equally effective as the older high-dose regimen (4.8 mg over 6 hours) but with dramatically fewer gastrointestinal side effects. 4, 2
In the pivotal AGREE trial, 37.8% of patients receiving low-dose colchicine achieved ≥50% pain reduction at 24 hours compared to only 15.5% with placebo (number needed to treat = 5). 4, 2
The low-dose regimen had an adverse event profile indistinguishable from placebo, while high-dose colchicine caused diarrhea in 76.9% of patients (versus 23% with low-dose). 4, 2
Critical Contraindications and Drug Interactions
Absolute contraindication: Do not give colchicine to patients taking strong P-glycoprotein or CYP3A4 inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir, atazanavir) - fatal toxicity has been reported. 3, 1
Avoid colchicine in severe renal impairment (GFR <30 mL/min). 3, 2
For patients on moderate CYP3A4 inhibitors or with moderate renal/hepatic impairment, reduce the acute dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, and do not repeat for at least 3 days. 1
In patients taking statins, monitor closely for neurotoxicity and muscular toxicity when using colchicine. 3, 5
If Colchicine Cannot Be Used
Oral corticosteroids: Prednisone or prednisolone 30-35 mg daily for 3-5 days is the preferred alternative. 3, 2
NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until the flare completely resolves, but avoid in patients with severe renal impairment, heart failure, or cirrhosis. 2
Intra-articular corticosteroid injection is an excellent option for monoarticular gout. 2, 5
Common Pitfalls to Avoid
Never use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or diarrhea) - this causes severe diarrhea in most patients with no additional benefit. 2
Do not exceed 1.8 mg in the first hour - higher doses provide no additional pain relief but substantially increase gastrointestinal toxicity. 2, 1
Do not delay treatment - waiting beyond 12-36 hours significantly reduces effectiveness. 2
If the patient is already on prophylactic colchicine (0.6 mg daily or twice daily), you can still give the acute treatment dose (1.2 mg followed by 0.6 mg one hour later), but then wait 12 hours before resuming the prophylactic dose. 1