What is the recommended dosing regimen for colchicine (Colchicine) in the treatment of an acute gout flare?

Colchicine Dosing for Acute Gout Flare

For an acute gout flare, administer colchicine 1.2 mg at the first sign of symptoms, followed by 0.6 mg one hour later (total 1.8 mg over 1 hour), but only if treatment can be initiated within 36 hours of symptom onset. 1, 2, 3

Timing is Critical

• Colchicine must be started within 12-36 hours of flare onset for maximum effectiveness—beyond this window, efficacy drops significantly and the medication should not be used 1, 2
• The "pills in the pocket" approach allows patients to self-administer at the earliest sign of symptoms 4

Standard Dosing Regimen

Initial Treatment:

• Loading dose: 1.2 mg (two 0.6 mg tablets) immediately 1, 2, 3
• Second dose: 0.6 mg (one tablet) exactly one hour later 1, 2, 3
• Total maximum dose: 1.8 mg over one hour 1, 2, 3

Post-Initial Treatment:

• Wait 12 hours after the second dose 2, 3
• Then continue with 0.6 mg once or twice daily until the flare resolves 1, 2

Evidence Supporting Low-Dose Regimen

The low-dose regimen (1.8 mg total) is as effective as higher doses with dramatically fewer side effects 1, 2. A pivotal randomized controlled trial demonstrated that 37.8% of patients achieved ≥50% pain reduction at 24 hours with low-dose colchicine versus only 15.5% with placebo, while the adverse event profile was indistinguishable from placebo 5. In contrast, high-dose colchicine (4.8 mg over 6 hours) caused diarrhea in 76.9% of patients, with 19.2% experiencing severe diarrhea 5.

Critical Dose Adjustments for Renal Impairment

Severe Renal Impairment (eGFR <30 mL/min):

• Colchicine should be avoided entirely—use glucocorticoids instead 1, 2
• If colchicine must be used: single 0.6 mg dose only, with no repeat dosing for at least 2 weeks 2, 3

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

• Reduce to single 0.6 mg dose with no repeat treatment for at least 2 weeks 1, 2

Mild Impairment (eGFR ≥60 mL/min):

• Standard dosing can be used if eGFR ≥30 mL/min 2

Dialysis Patients:

• Single 0.6 mg dose only, not to be repeated before 2 weeks 2, 3

Absolute Contraindications: Drug Interactions

Do not administer colchicine with strong CYP3A4 and/or P-glycoprotein inhibitors 1, 2, 3:

• Clarithromycin, erythromycin 1, 2
• Cyclosporine 1, 2
• Ketoconazole, itraconazole 2
• Ritonavir/nirmatrelvir (Paxlovid) 2
• Verapamil, diltiazem 2

These combinations dramatically increase colchicine levels and risk of fatal toxicity 2, 3.

Common Pitfalls to Avoid

Failure to calculate eGFR before prescribing is a critical error—real-world data shows physicians commonly prescribe excessive doses (mean 2.8 mg in first 24 hours, 6.9 mg over 3 days) without adjusting for renal function or age 6. This practice leads to preventable toxicity.

Starting treatment beyond 36 hours of symptom onset wastes medication and exposes patients to unnecessary side effects without benefit 1, 2.

Not screening for drug interactions before prescribing can result in life-threatening colchicine toxicity 2.

Alternative Treatments When Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses until complete resolution 2
• Oral corticosteroids: Prednisone 30-35 mg/day for 3-5 days, or 0.5 mg/kg/day for 5-10 days 2
• Intra-articular corticosteroid injection for single or few joint involvement 2