Can Colchicine and Allopurinol Be Started Together for a Gout Flare?
Yes, colchicine and allopurinol should be started together when initiating urate-lowering therapy during or after a gout flare, with colchicine serving as prophylaxis against flare recurrence rather than as primary treatment for the acute attack itself. 1
Treatment Strategy for Acute Gout Flare
When a patient presents with an active gout flare, the immediate priority is treating the acute inflammation with appropriate anti-inflammatory therapy:
- Treat the acute flare first with colchicine (1.2 mg at first sign, then 0.6 mg one hour later), NSAIDs, or corticosteroids 2
- Start allopurinol concurrently at a low dose (100 mg daily) even during the acute flare 1
- Continue colchicine prophylactically at 0.5-1.0 mg daily after treating the acute attack 2
FDA-Approved Dosing When Starting Both Medications
The FDA label explicitly addresses this scenario: "Maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun." 1
Specific dosing regimen:
- Allopurinol: Start 100 mg daily, increase weekly by 100 mg increments until serum urate <6 mg/dL (maximum 800 mg/day) 1
- Colchicine prophylaxis: 0.6 mg once or twice daily (maximum 1.2 mg/day for prophylaxis) 3
- Duration: Continue prophylaxis for at least 6 months 2
Evidence Supporting Concurrent Initiation
High-quality evidence demonstrates that prophylactic colchicine significantly reduces flares when starting allopurinol:
- Colchicine prophylaxis reduces total flares by 82% (0.52 vs 2.91 flares, p=0.008) 4
- Flares are less severe (VAS 3.64 vs 5.08, p=0.018) and recurrent flares are significantly reduced 4
- Prophylaxis for >8 weeks is more effective than shorter durations, with moderate-quality evidence supporting 6-month duration 2
Critical Safety Considerations Before Starting Colchicine
Absolute contraindications to colchicine:
- Severe renal impairment (GFR <30 mL/min): Colchicine clearance is markedly decreased and should be avoided 2, 5
- Concurrent strong CYP3A4 or P-glycoprotein inhibitors in patients with any degree of renal or hepatic impairment 5, 3
- Specific contraindicated drugs: Cyclosporin, clarithromycin, ketoconazole, ritonavir, verapamil 5, 3
Dose adjustments required:
- Moderate renal impairment (CrCl 30-50 mL/min): Reduce colchicine dose and monitor closely 2, 5
- Statin co-prescription: Increased risk of neurotoxicity and myopathy, particularly with renal impairment 2, 5, 6
- Despite concerns, statins were not associated with increased adverse events in a large cohort study of 13,945 patients 6
Common Pitfalls to Avoid
Starting allopurinol at too high a dose:
- Beginning at 100 mg daily reduces flare risk by 68% compared to higher starting doses (OR 3.21 for flares with higher doses) 7
- The "start-low go-slow" strategy with weekly 100 mg increments is evidence-based 1
Inadequate prophylaxis duration:
- Stopping prophylaxis at 8 weeks doubles the flare rate 2
- Continue for at least 6 months, or longer if flares persist or serum urate target not achieved 2, 7
Failing to screen for drug interactions:
- 26% of patients starting allopurinol with colchicine have potentially interacting medications, most commonly statins (21%) 6
- Always review medication list for CYP3A4/P-gp inhibitors before prescribing colchicine 2, 5, 3
Patients at Highest Risk for Flares Requiring Prophylaxis
Target prophylaxis particularly for:
- Patients with gout flare in the month before starting allopurinol (OR 2.65 for subsequent flares) 7
- Those starting allopurinol 100 mg daily (higher risk than lower doses) 7
- Patients with serum urate ≥0.36 mmol/L (6 mg/dL) at 6 months (OR 2.85 for flares) 7
Low-Dose vs Regular-Dose Colchicine Prophylaxis
Low-dose colchicine (0.6 mg daily) is as effective as regular-dose (1.2 mg daily) with fewer adverse events: