Can Colchicine Be Taken With Allopurinol?
Yes, colchicine can and should be taken with allopurinol—in fact, colchicine prophylaxis is specifically recommended when initiating allopurinol therapy to prevent acute gout flares that commonly occur during the first 6 months of urate-lowering treatment. 1, 2
Standard Prophylaxis Protocol
When starting allopurinol for gout, colchicine prophylaxis is the recommended standard of care:
- Prophylactic colchicine should be given at 0.5-1 mg daily (or up to 1.2 mg daily) for the first 6 months of allopurinol therapy 3, 2
- The FDA drug label explicitly states that "maintenance doses of colchicine generally should be given prophylactically when allopurinol tablets are begun" 1
- This combination reduces both the frequency and severity of acute gout flares during the critical early phase of urate-lowering therapy 4
Evidence Supporting Combined Use
The combination is well-established and evidence-based:
- A landmark randomized controlled trial demonstrated that patients receiving colchicine prophylaxis with allopurinol experienced significantly fewer total flares (0.52 vs 2.91 flares, p=0.008) compared to placebo 4
- Colchicine-treated patients had less severe flares on visual analog scale (3.64 vs 5.08, p=0.018) and fewer recurrent flares 4
- Multiple international guidelines from EULAR (2017,2006) and the 3e Initiative (2014) consistently recommend this combination 3
Critical Safety Considerations
While the combination is safe and recommended, specific precautions are essential:
Renal Impairment
- Reduce colchicine dose in patients with renal impairment 3, 2
- Avoid colchicine entirely in severe renal failure (GFR <30 mL/min) 3
- The safe use of colchicine has not been established in severe renal impairment, and reduced clearance increases toxicity risk 3
Drug Interactions
- Avoid co-prescribing colchicine with strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole, ritonavir, verapamil) 3
- These interactions can dramatically increase colchicine plasma concentrations, exposing patients to serious neurotoxicity and muscular toxicity 3
- Exercise caution when combining colchicine with statins, as this increases risk of myopathy, though statins alone were not associated with increased adverse events in one large cohort 5
Monitoring for Toxicity
- Watch for diarrhea (most common adverse effect), nausea, vomiting, myalgia, myopathy, neuropathy, and bone marrow suppression 5, 4
- Patients with more comorbidities and certain interacting medications have higher rates of adverse events 5
Dosing Strategy
The optimal approach combines both medications strategically:
Allopurinol Initiation
- Start allopurinol at 100 mg daily and increase by 100 mg increments every 2-4 weeks until target serum urate <6 mg/dL is achieved 3, 2, 1
- Maximum dose is 800 mg per day 1
- Lower starting doses (50-100 mg) are needed in renal impairment 3, 2
Colchicine Dosing
- Standard prophylactic dose: 0.5-1 mg daily 3, 2
- Recent evidence suggests low-dose colchicine (0.6 mg/day) may be as effective as regular-dose (1.2 mg/day) with fewer adverse events 6
- Duration: Continue for at least 6 months after starting allopurinol 3, 2
Common Pitfalls to Avoid
Failing to provide prophylaxis: This leads to increased acute flares, potentially reducing medication adherence and treatment success 2
Using colchicine with azathioprine: The one critical exception is that allopurinol should NOT be combined with azathioprine (AZA), as this increases risk of AZA toxicity including myelosuppression 3—but this is an allopurinol-azathioprine interaction, not a colchicine issue
Inadequate dose adjustment in renal disease: Both drugs require dose modification in renal impairment 3, 2
Premature discontinuation: Stopping prophylaxis before 6 months often results in a spike in acute attacks 3
Alternative Prophylaxis Options
If colchicine is contraindicated or not tolerated: