What is the recommended dose of colchicine (Colcrys) for various medical conditions?

Colchicine Dosing Recommendations

Acute Gout Flare Treatment

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 over one hour), but only if treatment is initiated within 36 hours of symptom onset. 1, 2, 3

Key Dosing Details for Acute Treatment

• The FDA-approved regimen is 1.2 mg (two tablets) initially, then 0.6 mg (one tablet) one hour later 3, 4
• This low-dose regimen is equally effective as older high-dose regimens but with significantly fewer gastrointestinal side effects 5, 6
• After the initial loading doses, continue with 0.6 mg once or twice daily (starting 12 hours after initial doses) until the flare resolves 2, 3
• Colchicine effectiveness drops dramatically if not started within 36 hours of symptom onset—do not use beyond this window 1, 2, 7

Critical Pitfall to Avoid

The outdated high-dose regimen (continuing colchicine every 1-2 hours until diarrhea develops) should never be used—it causes severe gastrointestinal toxicity without additional benefit 5, 6

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Gout Flare Prophylaxis

For prophylaxis during urate-lowering therapy, use colchicine 0.6 mg once or twice daily, initiated at the start of urate-lowering therapy and continued for at least 6 months. 1, 2, 3

Duration of Prophylaxis

• Minimum duration: 6 months after starting urate-lowering therapy 5, 2
• Alternative stopping points:
  • 3 months after achieving target serum urate in patients without tophi 5, 1
  • 6 months after achieving target serum urate with resolution of previously detected tophi 5, 1, 7

Important Context

Even with prophylaxis, breakthrough gout flares remain common in the first 6 months of urate-lowering therapy 5

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Familial Mediterranean Fever (FMF)

For FMF in adults, start with 1.2 to 2.4 mg daily, given as a single dose or divided into two doses, and titrate in 0.3 mg increments based on disease control and tolerability. 3

Pediatric FMF Dosing

• Ages 4-6 years: 0.3 to 1.8 mg daily 3
• Ages 6-12 years: 0.9 to 1.8 mg daily 3
• Adolescents >12 years: 1.2 to 2.4 mg daily 3

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Dose Adjustments for Renal Impairment

Acute Gout Treatment

• Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment needed, but monitor closely 3
• Severe impairment (CrCl <30 mL/min): Use standard acute dose (1.2 mg then 0.6 mg), but do not repeat treatment course for at least 2 weeks 3
• Dialysis patients: Single dose of 0.6 mg only; do not repeat for at least 2 weeks 7, 3

Prophylaxis Dosing

• Mild to moderate impairment: No adjustment required, but monitor closely 3
• Severe impairment (CrCl <30 mL/min): Start with 0.3 mg daily 3
• Dialysis patients: 0.3 mg twice weekly 3

Critical Safety Point

Do not treat acute gout flares with colchicine in patients already receiving prophylactic colchicine who have renal impairment 3

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Dose Adjustments for Drug Interactions

Strong CYP3A4 or P-glycoprotein Inhibitors

Colchicine is absolutely contraindicated with strong CYP3A4/P-gp inhibitors (clarithromycin, ketoconazole, ritonavir, etc.) in patients with renal or hepatic impairment—fatal toxicity has been reported. 1, 3

For Patients with Normal Renal/Hepatic Function:

• Acute gout treatment: 0.6 mg × 1 dose, then 0.3 mg one hour later; do not repeat for 3 days 3
• Prophylaxis: Maximum 0.3 mg once daily (or 0.6 mg every other day if taking 0.6 mg daily) 3
• FMF: Maximum 0.6 mg daily (may give as 0.3 mg twice daily) 3

Moderate CYP3A4 Inhibitors

For drugs like diltiazem, verapamil, erythromycin, or grapefruit juice 3:

• Acute gout treatment: 1.2 mg × 1 dose only; do not repeat for 3 days 3
• Prophylaxis: 0.3 mg twice daily or 0.6 mg once daily 3
• FMF: Maximum 1.2 mg daily (may give as 0.6 mg twice daily) 3

Additional High-Risk Interaction

Concomitant statin use increases risk of myopathy—monitor closely for muscle symptoms 2, 8

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Dose Adjustments for Hepatic Impairment

• Mild to moderate impairment: No dose adjustment required, but monitor closely 3
• Severe impairment: For acute treatment, use standard dose but do not repeat for at least 2 weeks; for prophylaxis and FMF, consider dose reduction 3
• Do not treat acute gout flares in patients on prophylactic colchicine who have hepatic impairment 3

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Safety Monitoring

Common Adverse Effects

• Gastrointestinal intolerance (diarrhea, nausea, vomiting) occurs in approximately 10% of patients at recommended doses 9
• At low doses (0.5-1.0 mg daily), approximately 90% of patients tolerate colchicine well long-term 9

Serious Toxicity Warning

Acute ingestions exceeding 0.5 mg/kg are associated with high fatality rates; the lowest reported lethal oral dose is 7 mg 8

Essential Pre-Treatment Assessment

Always calculate creatinine clearance before prescribing colchicine, especially in elderly patients, to avoid life-threatening toxicity 1, 2