What is the recommended dosage of Colchicine for managing gout attacks?

Colchicine Dosing for Acute Gout

For acute gout attacks, administer colchicine 1.2 mg at the 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 the attack resolves, but only if treatment starts within 36 hours of symptom onset. 1, 2, 3

Acute Attack Treatment Regimen

Initial Loading Dose

• Give 1.2 mg (two tablets) immediately at first sign of gout flare 1, 2, 3
• Follow with 0.6 mg (one tablet) exactly one hour later 1, 2, 3
• Total loading dose is 1.8 mg over one hour 1, 4, 5
• Do not exceed 1.8 mg in the first hour—higher doses provide no additional benefit but substantially increase gastrointestinal toxicity 1, 6

Critical Timing Window

• Treatment must begin within 36 hours of symptom onset; effectiveness drops significantly beyond this timeframe 1, 2, 4
• Optimal efficacy occurs when started within 12 hours of symptoms 1
• Colchicine should not be used if the attack started more than 36 hours ago 2, 4

Continuation Dosing

• Wait 12 hours after the loading doses before resuming any colchicine 1, 2
• Then continue 0.6 mg once or twice daily (maximum 1.2 mg/day) until the attack completely resolves 1, 2, 3
• If already taking prophylactic colchicine when the attack occurs, take the full loading dose, then wait 12 hours before resuming the prophylactic regimen 1

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg) for achieving 50% or greater pain reduction at 24 hours, with a number needed to treat of 5 1, 7, 6
• Low-dose colchicine produces significantly fewer gastrointestinal adverse events compared to high-dose regimens 1, 7, 5, 6
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 1, 8

Absolute Contraindications

Do not give colchicine in these situations:

• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, itraconazole) or P-glycoprotein inhibitors (cyclosporine) 1, 2, 4, 3
• Severe renal impairment (eGFR <30 mL/min/1.73 m²) 1, 2, 4
• Patients with both renal or hepatic impairment AND taking potent CYP3A4 or P-glycoprotein inhibitors 1

Dose Adjustments for Renal Impairment

• eGFR ≥30 mL/min: Use standard dosing (1.2 mg followed by 0.6 mg one hour later) 4
• eGFR 15-29 mL/min (severe impairment): Reduce to single dose of 0.6 mg with no repeat treatment for at least two weeks 2, 4
• Dialysis patients: Single dose of 0.6 mg, do not repeat before two weeks 4

Alternative Treatments When Colchicine Cannot Be Used

First-Line Alternatives

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 1, 4
• Oral corticosteroids: Prednisone 30-35 mg/day for 3-5 days, or 0.5 mg/kg/day for 5-10 days then taper over 7-10 days 1, 4
• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement 1, 4

Preferred in Severe Renal Impairment

• Glucocorticoids are the preferred first-line treatment over colchicine when eGFR <30 mL/min 4

Prophylaxis Dosing (Separate from Acute Treatment)

• Standard prophylactic dose is 0.6 mg once or twice daily (maximum 1.2 mg/day) 2, 3
• Initiate prophylaxis with or just prior to starting urate-lowering therapy 2, 4
• Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi present, or 6 months after achieving target if tophi present 2, 4

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens (>1.8 mg in first hour)—they offer no additional benefit and cause severe gastrointestinal toxicity 1, 6
• Do not delay treatment beyond 36 hours of symptom onset 1, 2, 4
• Always screen for drug interactions with CYP3A4/P-glycoprotein inhibitors before prescribing 1, 4, 3
• Calculate eGFR before prescribing colchicine to identify patients requiring dose adjustment or alternative therapy 4
• Do not use colchicine as an analgesic for non-gout pain 3