What is the recommended dosage of Colchicine (Colchicine) for treating acute gout attacks and other conditions?

Colchicine Dosing for Gout

Acute Gout Flare Treatment

For acute gout attacks, 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), then continue 0.6 mg once or twice daily until the attack resolves. 1, 2, 3

Critical Timing Requirements

• Start treatment within 36 hours of symptom onset—effectiveness drops dramatically beyond this window 1, 2, 3
• Optimal efficacy occurs when initiated within 12 hours of first symptoms 1
• If already taking prophylactic colchicine when an attack occurs, take the loading dose (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the regular prophylactic dose 1, 3

Evidence Supporting Low-Dose Regimen

• The low-dose regimen (1.8 mg total) is as effective as high-dose colchicine (4.8 mg) but with significantly fewer gastrointestinal side effects 1, 4
• Number needed to treat (NNT) is 5 for achieving 50% or greater pain reduction at 24 hours 1
• The older high-dose regimen (0.5 mg every 2 hours until relief or toxicity) is obsolete and causes severe diarrhea in most patients 1

Prophylaxis of Gout Flares

The recommended dose for prophylaxis is 0.6 mg once or twice daily (maximum 1.2 mg/day). 2, 3

Duration of Prophylaxis

• Continue for at least 6 months after starting urate-lowering therapy 2
• If no tophi present: continue for 3 months after achieving target serum urate 2
• If tophi are present: continue for 6 months after achieving target serum urate 2

When to Initiate Prophylaxis

• Start prophylaxis with or just prior to initiating urate-lowering therapy (allopurinol, febuxostat, pegloticase) 3
• Prophylaxis prevents the increase in gout flares that commonly occurs when starting urate-lowering therapy due to mobilization of urate from tissue deposits 3

Dose Adjustments for Renal Impairment

Severe Renal Impairment (eGFR 15-29 mL/min/1.73 m²)

• Reduce prophylactic dose to 0.3 mg daily 2
• For acute gout: single dose of 0.6 mg, do not repeat for at least 2 weeks 5

End-Stage Renal Disease (Dialysis)

• Single dose of 0.6 mg only, not to be repeated before 2 weeks 5

Severe Renal Impairment (eGFR <30 mL/min)

• Avoid colchicine entirely according to European guidelines 2
• Consider alternative prophylaxis with low-dose NSAIDs (with proton pump inhibitor) or low-dose prednisone ≤10 mg/day 2

Critical Drug Interactions

Colchicine is absolutely contraindicated with concurrent use of strong CYP3A4 inhibitors or P-glycoprotein inhibitors, especially in patients with renal or hepatic impairment. 1, 3

Strong CYP3A4/P-gp Inhibitors (Contraindicated)

• Clarithromycin, erythromycin, cyclosporine, ketoconazole, itraconazole, ritonavir, atazanavir, indinavir, nelfinavir, saquinavir, telithromycin 1, 3

Dose Adjustments if Strong Inhibitors Cannot Be Avoided

• Prophylaxis: reduce from 0.6 mg twice daily to 0.3 mg once daily 3
• Acute gout: reduce from 1.2 mg + 0.6 mg to 0.6 mg × 1 dose followed by 0.3 mg one hour later, not to be repeated for at least 3 days 3
• Maximum daily dose: 0.6 mg (may be given as 0.3 mg twice daily) 3

Alternative Treatment Options

When Colchicine is Contraindicated or Ineffective

First-line alternatives:

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 1, 5
• Oral corticosteroids: prednisone 0.5 mg/kg/day (or 30-35 mg/day) for 5-10 days, then stop or taper over 7-10 days 1, 5
• Intra-articular corticosteroid injection for monoarticular gout 1, 5

Combination Therapy for Severe Attacks

• Initial combination of colchicine plus NSAIDs is appropriate for severe attacks involving multiple large joints or polyarticular arthritis 1
• Provides synergistic anti-inflammatory effects through different pathways 1
• Caution: avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Common Pitfalls to Avoid

• Never use high-dose colchicine (>1.8 mg in first hour)—no additional benefit but substantially increased gastrointestinal toxicity 1
• Do not delay treatment beyond 36 hours after symptom onset 1, 2
• Monitor for neurotoxicity and myotoxicity, especially in patients with renal impairment or concurrent statin therapy 2
• NSAIDs should be used cautiously in patients with renal disease, heart failure, or cirrhosis 1

First-Line Treatment Recommendation Summary

Colchicine and NSAIDs are both first-line agents for acute gout attacks; in the absence of contraindications, an NSAID is a convenient and well-accepted option. 6 However, the low-dose colchicine regimen (1.8 mg total over one hour) offers comparable efficacy with fewer side effects than historical high-dose regimens and remains an excellent first-line choice when started early 1, 4.