Colchicine Dosing for Acute Gout
For acute gout, administer colchicine 1.2 mg at the first sign of flare followed by 0.6 mg one hour later (total 1.8 mg over one hour), but only if started within 36 hours of symptom onset. 1, 2, 3
Acute Treatment Regimen
The low-dose regimen (1.8 mg total) is as effective as higher doses with significantly fewer gastrointestinal side effects. 4, 1, 5
- Start with 1.2 mg (two tablets) at the first sign of the gout flare 3
- Follow with 0.6 mg (one tablet) exactly one hour later 3
- Do not exceed 1.8 mg total over the one-hour period 3
- Higher doses (such as the older regimen of 4.8 mg over 6 hours) provide no additional benefit but cause substantially more diarrhea (76.9% vs 23.0%) and vomiting (17.3% vs 0%) 5
Critical Timing Window
Colchicine effectiveness drops dramatically if not started within 36 hours of symptom onset. 1, 2
- Ideally initiate within 12-36 hours of flare onset for maximum effectiveness 1, 2
- Beyond 36 hours, consider alternative treatments (NSAIDs or corticosteroids) 4
Post-Acute Dosing
After the initial 1.8 mg loading doses, continue prophylactic dosing: 1, 2
- Resume 0.6 mg once or twice daily beginning 12 hours after the loading doses 1
- Continue until the gout attack completely resolves 1, 2
Dose Adjustments for Renal Impairment
Renal function critically determines safe colchicine dosing. 1, 2
- eGFR ≥30 mL/min: Use standard low-dose regimen (1.2 mg followed by 0.6 mg one hour later) 1
- eGFR <30 mL/min (severe renal impairment): Avoid colchicine entirely; use glucocorticoids instead 1, 2
- Dialysis patients: Single 0.6 mg dose only, do not repeat for at least two weeks 1
- Moderate renal impairment: Reduce to single 0.6 mg dose with no repeat treatment for at least two weeks 1, 2
Absolute Contraindications
Do not prescribe colchicine if the patient is taking strong CYP3A4 or P-glycoprotein inhibitors, especially in renal impairment. 1, 2, 3
Contraindicated medications include: 1, 2
- Clarithromycin or erythromycin
- Cyclosporine
- Ketoconazole or itraconazole
- Verapamil or diltiazem
- Ritonavir/nirmatrelvir (Paxlovid)
Prophylaxis Dosing (Separate Indication)
For preventing gout flares (not treating acute attacks): 4, 3
- Standard dose: 0.6 mg once or twice daily 4, 3
- Maximum prophylactic dose: 1.2 mg/day 3
- Continue for at least 6 months when initiating urate-lowering therapy 4, 3
Alternative Treatments When Colchicine is Inappropriate
Corticosteroids should be considered first-line therapy due to superior safety profile and lower cost. 4
- Prednisolone 35 mg daily for 5 days 4
- Prednisone 0.5 mg/kg/day for 5-10 days, then stopped or tapered over 7-10 days 1
- Intra-articular corticosteroid injection for single or few joint involvement 1, 2
- NSAIDs at full FDA-approved doses until complete resolution (if no contraindications) 4, 1
Common Pitfalls to Avoid
- Starting colchicine beyond 36 hours of symptom onset significantly reduces effectiveness 1, 2
- Failing to check renal function before prescribing can lead to severe toxicity 1, 2
- Not screening for drug interactions with CYP3A4/P-glycoprotein inhibitors risks life-threatening colchicine toxicity 1, 2
- Using high-dose regimens (>1.8 mg in first hour) provides no additional benefit but causes substantially more adverse effects 4, 5
- Prescribing colchicine as an analgesic for non-gout pain is inappropriate 3