What are the dose and duration for colchicine and indomethacin (Non-Steroidal Anti-Inflammatory Drug) in the treatment of acute gout?

Colchicine and Indomethacin Dosing for Acute Gout

For acute gout, use colchicine 1.2 mg at first sign of flare followed by 0.6 mg one hour later (total 1.8 mg), then continue 0.6 mg once or twice daily until attack resolves; for indomethacin, use full FDA-approved doses continuously until complete resolution. 1, 2

Colchicine Dosing

Acute Attack Treatment

• Loading dose: 1.2 mg (two tablets) at 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 3, 2
• Critical timing: Must be started within 36 hours of symptom onset for effectiveness 1, 3, 2
• After loading: Wait 12 hours, then resume 0.6 mg once or twice daily until attack completely resolves 1, 2

Evidence Supporting Low-Dose Regimen

• Low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg) for achieving ≥50% pain reduction at 24 hours 3, 4, 5
• Number needed to treat: 5 patients for 50% pain reduction 3
• Significantly fewer gastrointestinal side effects compared to high-dose regimens (23% vs 77% diarrhea rate) 4, 5
• High-dose regimens provide no additional benefit but substantially increase toxicity 3, 4

Special Circumstances

• If already on prophylactic colchicine: Give the loading dose (1.2 mg + 0.6 mg), wait 12 hours, then resume regular prophylactic dosing 1, 2
• Maximum dose for acute treatment: 1.8 mg over one hour period 2

Indomethacin Dosing

Acute Attack Treatment

• Use full FDA-approved doses until the gouty attack has completely resolved 1, 3
• Indomethacin is one of three NSAIDs specifically FDA-approved for acute gout (along with naproxen and sulindac) 1, 3
• Continue at full dose without tapering until complete resolution of symptoms 1

Duration Considerations

• Treatment duration is symptom-driven—continue until attack fully resolves, not a fixed number of days 1
• No evidence suggests one NSAID is more effective than another for gout 3

Important Caveats and Contraindications

Colchicine Contraindications

• Absolute contraindication: Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin) or P-glycoprotein inhibitors (cyclosporine) 3, 2
• Severe renal impairment (GFR <30 mL/min): Avoid colchicine or use extreme caution with dose reduction 3, 6
• Patients with both renal/hepatic impairment AND taking potent CYP3A4/P-gp inhibitors should not receive colchicine 3

NSAID Precautions

• Use cautiously in patients with renal disease, heart failure, or cirrhosis 3
• Consider proton pump inhibitor co-administration for GI protection 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1, 3

Combination Therapy Option

• Colchicine plus NSAIDs is appropriate for severe attacks involving multiple large joints or polyarticular arthritis 1, 3
• Use full doses of both agents simultaneously for severe presentations 1
• This combination targets different inflammatory pathways for synergistic effect 3

Common Pitfalls to Avoid

• Don't delay treatment: Effectiveness drops significantly after 36 hours from symptom onset 1, 3, 2
• Don't use high-dose colchicine: The outdated regimen of 0.5 mg every 2 hours causes severe diarrhea in most patients with no additional benefit 3
• Don't stop urate-lowering therapy: Continue allopurinol or other ULT during acute attacks 1
• Don't use colchicine as an analgesic: It is not effective for pain from other causes 2