What is the proper dosing of colchicine (Colcrys) for managing a gout attack?

How to Take Colchicine During a Gout Attack

For an acute gout attack, take 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, 3

Critical Timing Window

• Start treatment within 36 hours of symptom onset - colchicine effectiveness drops significantly beyond this timeframe and is not recommended if the attack started more than 36 hours ago. 4, 2, 3
• The European League Against Rheumatism emphasizes that colchicine is most effective when administered within 12 hours of symptom onset, recommending a "pill in the pocket" approach for informed patients to self-medicate at the first warning symptoms. 2

After Initial Dosing

• Wait 12 hours after the initial loading doses, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves. 4, 2, 3
• If you are already taking prophylactic colchicine when the attack occurs, you can still take the loading dose (1.2 mg followed by 0.6 mg one hour later), but then wait 12 hours before resuming your regular prophylactic dose. 4, 1

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg over 6 hours) for pain reduction at 24 hours, with 37.8% of patients achieving ≥50% pain reduction versus 32.7% with high-dose. 2, 5
• The low-dose regimen has a dramatically better safety profile - only 23% experienced diarrhea compared to 77% with high-dose colchicine, and no patients had vomiting or severe diarrhea with low-dose versus 17-19% with high-dose. 5, 2
• The number needed to treat (NNT) with colchicine versus placebo is 3 for pain reduction and 2 for clinical symptoms. 6

Absolute Contraindications

Do not take colchicine if you are on any of these medications: 2, 3, 1

• Strong CYP3A4 inhibitors: clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir/nirmatrelvir (Paxlovid)
• P-glycoprotein inhibitors: cyclosporine
• This combination can cause life-threatening colchicine toxicity

Dose Adjustments for Kidney Disease

• If your eGFR is 30-60 mL/min: Use the standard low-dose regimen (1.8 mg over 1 hour) but monitor closely for side effects. 3
• If your eGFR is <30 mL/min or you are on dialysis: Colchicine should be avoided - use corticosteroids instead (prednisone 30-35 mg/day for 3-5 days or intra-articular injection). 2, 3

Alternative Options if Colchicine Cannot Be Used

If colchicine is contraindicated or not tolerated, the American College of Rheumatology recommends: 4, 2

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution
• Oral corticosteroids: Prednisone 0.5 mg/kg/day (typically 30-35 mg/day) for 5-10 days, then stop or taper over 7-10 days
• Intra-articular corticosteroid injection for single joint involvement

Common Pitfalls to Avoid

• Never use the old high-dose regimen (0.5 mg every 2 hours until relief or diarrhea) - this is obsolete and causes severe diarrhea in most patients without additional benefit. 2
• Do not delay treatment - waiting beyond 12-36 hours significantly reduces effectiveness. 2, 3
• Do not exceed 1.8 mg in the first hour - higher doses provide no additional benefit but substantially increase gastrointestinal toxicity. 2, 5
• Check for drug interactions before taking colchicine - concurrent use with certain antibiotics and immunosuppressants can be fatal. 2, 3, 1