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 of 1.8 mg over one hour. 1
Critical Timing Window
- Treatment must be initiated within 12 hours of symptom onset for optimal efficacy, with effectiveness dropping significantly after 36 hours 2, 3
- Patients should be educated to self-medicate at the first warning symptoms using a "pill in the pocket" approach 2, 3
After Initial Loading Dose
- Wait 12 hours after the initial 1.8 mg loading dose, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves 3, 1
- If already taking prophylactic colchicine when the flare occurs, take 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
Evidence Supporting Low-Dose Regimen
- This low-dose regimen (1.8 mg total) is as effective as the older high-dose regimen (4.8 mg over 6 hours) for achieving ≥50% pain reduction at 24 hours, but with significantly fewer gastrointestinal side effects 3, 4, 5
- Higher doses beyond 1.8 mg provide no additional benefit but substantially increase toxicity 3, 1
- The obsolete regimen of 0.5 mg every 2 hours until relief or toxicity should never be used, as it causes severe diarrhea in most patients 3
Absolute Contraindications
- Do not give colchicine to patients taking strong P-glycoprotein and/or CYP3A4 inhibitors (cyclosporin, clarithromycin, erythromycin, ketoconazole, ritonavir) as this dramatically increases colchicine plasma concentrations and risk of fatal toxicity 2, 3, 6
- Avoid colchicine entirely in severe renal impairment (GFR <30 mL/min or dialysis patients), where only a single 0.6 mg dose is the maximum allowed and cannot be repeated for at least two weeks 6, 1
Alternative Options When Colchicine is Contraindicated
- Oral corticosteroids: Prednisone 30-35 mg/day (or equivalent prednisolone) for 3-5 days 2, 3
- NSAIDs: Full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution, but avoid in severe renal impairment 2, 3
- Intra-articular corticosteroid injection: Excellent option for monoarticular gout after excluding septic arthritis 3
Common Pitfalls to Avoid
- Never delay treatment beyond 36 hours after symptom onset, as this significantly reduces effectiveness 3, 5
- Never use high-dose regimens (>1.8 mg in first hour), as they provide no additional benefit but cause severe gastrointestinal toxicity 3
- Never ignore renal function when prescribing colchicine, as this is a frequent cause of serious toxicity in real-world practice 7
- Never combine colchicine with strong CYP3A4 inhibitors, as fatal colchicine toxicity has been reported with this combination 3, 8