Colchicine Treatment for Gout Arthritis
For acute gout flares, administer colchicine 1.2 mg at the first sign of symptoms followed by 0.6 mg one hour later (total 1.8 mg), then continue 0.6 mg once or twice daily until the attack resolves, starting 12 hours after the initial loading doses. 1, 2
Acute Gout Flare Treatment
Standard Dosing Protocol
- Loading dose: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later 2
- Maximum acute dose: 1.8 mg over one hour period 2
- Continuation: After 12 hours, resume prophylactic dosing of 0.6 mg once or twice daily until attack resolves 3, 1
- Critical timing: Treatment must be initiated within 36 hours of symptom onset for effectiveness 1, 4
This low-dose regimen (1.8 mg total) is as effective as the older high-dose regimens (4.8 mg) but with significantly fewer gastrointestinal side effects. 1, 5 The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients. 1
Evidence Quality
The AGREE trial demonstrated that low-dose colchicine achieved a 50% or greater pain reduction with a number needed to treat (NNT) of 5, with equal efficacy to high-dose regimens but substantially better tolerability. 1 Higher doses provide no additional benefit but substantially increase gastrointestinal toxicity. 1
Prophylaxis Dosing
Standard Prophylaxis Protocol
- Dose: 0.6 mg once or twice daily 3, 2
- Maximum prophylactic dose: 1.2 mg/day 2
- Initiation timing: Start with or just prior to initiating urate-lowering therapy 3
Duration of Prophylaxis
Continue prophylaxis for the greater of: 3
- At least 6 months, OR
- 3 months after achieving target serum urate (if no tophi detected on physical exam), OR
- 6 months after achieving target serum urate (if one or more tophi detected on physical exam)
The American College of Rheumatology recommends prophylactic therapy for at least the first six months of uric acid-lowering therapy, as gout flares commonly increase after initiating agents like allopurinol, febuxostat, or pegloticase due to mobilization of urate from tissue deposits. 2
Dose Adjustments for Renal Impairment
Prophylaxis in Renal Impairment
- Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment required, but monitor closely 2
- Severe impairment (CrCl <30 mL/min): Start with 0.3 mg/day; increase cautiously with close monitoring 1, 2
- Dialysis patients: 0.3 mg twice weekly with close monitoring 2
Acute Treatment in Renal Impairment
- Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment required, but monitor closely 2
- Severe impairment (CrCl <30 mL/min): Use standard acute dose (1.8 mg), but repeat treatment no more than once every two weeks 2
- Dialysis patients: Single dose of 0.6 mg only; do not repeat more than once every two weeks 2
Critical caveat: The European League Against Rheumatism recommends avoiding colchicine entirely in patients with severe renal impairment (eGFR <30 mL/min), preferring glucocorticoids as first-line treatment. 1 However, recent evidence from 54 hospitalized patients with severe CKD showed that reduced-dose colchicine (≤0.5 mg/day) was well tolerated in 77% of cases and completely effective in 83% of cases, with no serious adverse events reported. 6
Critical Drug Interactions
Absolute Contraindications
Do not use colchicine with strong CYP3A4 or P-glycoprotein inhibitors in patients with renal or hepatic impairment, as fatal colchicine toxicity has been reported. 1, 2
Strong inhibitors requiring contraindication include: 2
- Clarithromycin, erythromycin
- Ketoconazole, itraconazole
- Ritonavir-containing regimens
- Cyclosporine
Dose Adjustments with Moderate Inhibitors
When strong CYP3A4/P-gp inhibitors cannot be avoided: 2
- Prophylaxis: Reduce from 0.6 mg twice daily to 0.3 mg once daily, or from 0.6 mg once daily to 0.3 mg every other day
- Acute treatment: Single dose of 0.6 mg followed by 0.3 mg one hour later; do not repeat for at least 3 days
- FMF treatment: Maximum daily dose of 0.6 mg (may be given as 0.3 mg twice daily)
Alternative Therapies When Colchicine is Contraindicated
First-Line Alternatives
- NSAIDs: Full FDA-approved doses (e.g., naproxen 250 mg twice daily) until complete resolution 3, 7
- Oral corticosteroids: Prednisone 0.5 mg/kg/day (or 30-35 mg/day) for 5-10 days at full dose, then stop or taper over 7-10 days 3, 7
- Intra-articular corticosteroids: Dose varies by joint size; excellent option for monoarticular gout 3, 7
- Intramuscular corticosteroids: Triamcinolone acetonide 60 mg 3
Combination Therapy for Severe Attacks
Initial combination therapy is appropriate for acute, severe gout attacks, particularly with multiple large joints or polyarticular arthritis: 3
- Colchicine + NSAIDs
- Oral corticosteroids + colchicine
- Intra-articular steroids with any other modality
Important caveat: The American College of Rheumatology task force did not endorse combining NSAIDs with systemic corticosteroids due to concerns about synergistic gastrointestinal toxicity. 3
Common Pitfalls to Avoid
- Delaying treatment: Effectiveness significantly decreases beyond 36 hours of symptom onset 1, 4
- Using high-dose regimens: Provides no additional benefit but substantially increases gastrointestinal toxicity 1
- Ignoring drug interactions: Fatal toxicity has been reported with clarithromycin and other strong CYP3A4 inhibitors 1, 2
- Inadequate prophylaxis duration: Stopping prophylaxis too early increases risk of recurrent flares during urate-lowering therapy 8
- Treating colchicine as an analgesic: Colchicine is not an analgesic and should not be used to treat pain from other causes 2
Special Populations
Hepatic Impairment
Dose reduction required with moderate to severe hepatic impairment, particularly when combined with CYP3A4/P-gp inhibitors. 3, 2
Pediatric Use
Not recommended for prophylaxis or treatment of gout flares in pediatric patients. 2
Monitoring Requirements
Monitor patients on colchicine prophylaxis for neurotoxicity and myotoxicity, especially with concurrent statin therapy or renal impairment. 4