What is the recommended dosage of colchicine (Colchicine) tablets for treating acute gout attacks and prophylaxis?

Colchicine Dosing for Acute Gout and Prophylaxis

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 starting 12 hours after the loading dose until the attack resolves; for prophylaxis, use 0.6 mg once or twice daily for at least 6 months when initiating urate-lowering therapy. 1, 2

Acute Gout Treatment Dosing

Standard Regimen

• Loading dose: 1.2 mg (two tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later 1, 2
• Total initial dose: 1.8 mg over one hour 1, 2
• Continuation: After waiting 12 hours from the loading dose, resume 0.6 mg once or twice daily until the attack completely resolves 1, 3

Critical Timing Window

• Start treatment within 36 hours of symptom onset - effectiveness drops significantly beyond this timeframe 1, 3
• Optimal efficacy occurs when treatment begins within 12 hours of symptom onset 3
• The "pill in the pocket" approach allows fully informed patients to self-medicate at the first warning symptoms 3

Evidence Supporting Low-Dose Regimen

The low-dose regimen (1.8 mg total) is as effective as high-dose colchicine (4.8 mg over 6 hours) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat of 4-5, but with significantly fewer gastrointestinal adverse events 1, 4. High-dose regimens provide no additional benefit but cause diarrhea in 77% of patients versus 23% with low-dose 4.

Prophylaxis Dosing

Standard Prophylaxis

• Dose: 0.6 mg once or twice daily 1, 5, 2
• Maximum daily dose: 1.2 mg/day 2
• Initiation: Start with or just prior to beginning urate-lowering therapy (allopurinol, febuxostat, pegloticase) 1, 5

Duration of Prophylaxis

• Minimum duration: 6 months after starting urate-lowering therapy 1, 5
• Without tophi: Continue for 3 months after achieving target serum urate 1
• With tophi present: Continue for 6 months after achieving target serum urate 1

Managing Breakthrough Flares During Prophylaxis

If an acute flare occurs while already taking prophylactic colchicine, administer the full loading dose (1.2 mg followed by 0.6 mg one hour later), then wait 12 hours before resuming the regular prophylactic dose 3, 2.

Dose Adjustments for Renal Impairment

Severe Renal Impairment (eGFR <30 mL/min)

• Acute treatment: Single dose of 0.6 mg with no repeat treatment for at least two weeks 1, 5
• Prophylaxis: Reduce to 0.3 mg once daily (for eGFR 15-29 mL/min) 5
• Dialysis patients: Single dose of 0.6 mg, not repeated before two weeks 1
• Preferred alternative: Glucocorticoids are recommended as first-line treatment over colchicine in severe renal impairment 1

Moderate Renal Impairment (eGFR ≥30 mL/min)

Standard low-dose regimen (1.2 mg followed by 0.6 mg one hour later) can be used 1

Critical Drug Interactions

Absolute Contraindications

Do not use colchicine with strong CYP3A4 or P-glycoprotein inhibitors, especially in patients with renal or hepatic impairment 1, 2. These include:

• Clarithromycin 1, 2
• Erythromycin 1, 2
• Ketoconazole 1, 2
• Itraconazole 1, 2
• Ritonavir-containing regimens (including Paxlovid) 1, 2
• Cyclosporine 1, 2

Dose Adjustments for Moderate CYP3A4/P-gp Inhibitors

When strong inhibitors cannot be avoided in patients with normal renal/hepatic function 2:

• Prophylaxis: Reduce from 0.6 mg twice daily to 0.3 mg once daily 2
• Acute treatment: Reduce from 1.2 mg + 0.6 mg to 0.6 mg × 1 dose followed by 0.3 mg one hour later; do not repeat for at least 3 days 2

Alternative Treatment Options

When Colchicine is Contraindicated

• NSAIDs: Full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 1, 3
• Oral corticosteroids: Prednisone 30-35 mg/day (or 0.5 mg/kg/day) for 3-5 days, then stop or taper over 7-10 days 1, 3
• Intra-articular corticosteroids: For monoarticular or oligoarticular involvement (1-2 large joints) 1, 3

Combination Therapy for Severe Attacks

For severe gout attacks involving multiple large joints or polyarticular arthritis, combination therapy with colchicine and NSAIDs provides synergistic anti-inflammatory effects targeting different pathways 3.

Common Pitfalls to Avoid

• Never use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or toxicity) - this causes severe diarrhea in most patients with no additional benefit 1
• Do not delay treatment beyond 36 hours of symptom onset 1, 3
• Screen for drug interactions before prescribing, particularly CYP3A4/P-gp inhibitors 1
• Calculate eGFR immediately when considering colchicine for patients with known or suspected renal disease 1
• Monitor for neurotoxicity and myotoxicity in patients on prophylaxis, especially those with renal impairment or concurrent statin therapy 5