What is the recommended dose of colchicine for a gout flare-up?

Colchicine Dosing for Acute Gout Flare

For an acute gout flare, administer 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 maximum dose of 1.8 mg over one hour. 1

Initial Treatment Regimen

• The FDA-approved dosing is 1.2 mg followed by 0.6 mg one hour later, with a maximum of 1.8 mg in the first hour. 1
• Higher doses provide no additional benefit but substantially increase gastrointestinal toxicity. 2
• This low-dose regimen (1.8 mg total) is as effective as the older high-dose regimen (4.8 mg over 6 hours) but with significantly fewer side effects, with a number needed to treat of 5 for achieving 50% or greater pain reduction. 2

Critical Timing Considerations

• Start treatment within 36 hours of symptom onset—colchicine effectiveness drops significantly beyond this window. 2
• The European League Against Rheumatism emphasizes that colchicine is most effective when administered within 12 hours of symptom onset. 2
• Consider a "pill in the pocket" approach for fully informed patients to self-medicate at the first warning symptoms. 2

Continuation 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. 2
• If the patient was already taking prophylactic colchicine when the flare occurred, give the loading dose (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the regular prophylactic dose. 2, 1

Absolute Contraindications

• Do not give colchicine to patients taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir) or P-glycoprotein inhibitors (cyclosporine). 2, 1
• Fatal colchicine toxicity has been reported with clarithromycin, a strong CYP3A4 inhibitor. 1
• Avoid colchicine in patients with severe renal impairment (GFR <30 mL/min). 2
• Patients with both renal or hepatic impairment AND taking potent CYP3A4 or P-glycoprotein inhibitors should not use colchicine. 2

Dose Adjustments for Drug Interactions

• If the patient is on strong CYP3A4 inhibitors and colchicine cannot be avoided, reduce the acute dose to 0.6 mg × 1 dose, followed by 0.3 mg one hour later, with no repeat dosing for at least 3 days. 1
• For moderate CYP3A4 inhibitors (diltiazem, verapamil, fluconazole, grapefruit juice), reduce the acute dose to 1.2 mg × 1 dose with no repeat dosing for at least 3 days. 1

Alternative Options if Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution are the first alternative. 2
• Oral corticosteroids (prednisone 0.5 mg/kg/day, approximately 30-35 mg for average adults) for 5-10 days at full dose then stopped, or given for 2-5 days followed by tapering over 7-10 days. 3
• Intra-articular corticosteroid injection is excellent for monoarticular gout involving 1-2 large joints. 2, 3
• Intramuscular triamcinolone acetonide 60 mg is recommended when patients are NPO or cannot tolerate oral medications. 3

Combination Therapy for Severe Flares

• For severe attacks involving multiple large joints or polyarticular arthritis, combination therapy with colchicine and NSAIDs is appropriate. 2
• The combination provides synergistic anti-inflammatory effects targeting different inflammatory pathways. 2
• Avoid combining NSAIDs with systemic corticosteroids due to concerns about synergistic gastrointestinal toxicity. 2

Common Pitfalls to Avoid

• The obsolete regimen of 0.5 mg every 2 hours until relief or toxicity causes severe diarrhea in most patients and should never be used. 2
• Do not delay treatment beyond 12-36 hours after symptom onset, which significantly reduces effectiveness. 2
• Do not use colchicine as an analgesic for pain from other causes—it is not an analgesic medication. 1
• The safety and efficacy of repeat treatment for gout flares has not been evaluated, so use caution with frequent repeat dosing. 1