Colchicine Dosing for Acute Gout and Familial Mediterranean Fever
For acute gout, administer colchicine 1.2 mg at the first sign of flare followed by 0.6 mg one hour later (total 1.8 mg), but only if treatment begins within 36 hours of symptom onset; for prophylaxis use 0.6 mg once or twice daily; for FMF use 1.2-2.4 mg daily in adults. 1, 2, 3, 4
Acute Gout Treatment
The FDA-approved and guideline-recommended regimen is:
- 1.2 mg (two tablets) at first sign of flare
- Followed by 0.6 mg (one tablet) one hour later
- Maximum dose: 1.8 mg over one hour 1, 3, 4
Critical timing consideration: Colchicine is only effective if started within 36 hours of symptom onset—effectiveness significantly decreases beyond this window. 1, 2, 3
After the initial loading doses, continue with prophylactic dosing of 0.6 mg once or twice daily (starting 12 hours after the initial doses) until the gout attack resolves. 1, 2, 4
Important Context on Dosing Evolution
The older high-dose regimen (1 g loading dose followed by 0.5 mg every 2-3 hours) should never be used—it causes severe gastrointestinal toxicity with no additional benefit. 5 The low-dose regimen (1.8 mg total) is equally effective with significantly fewer side effects. 1, 3, 6
Gout Flare Prophylaxis
Standard prophylactic dosing:
- 0.6 mg once or twice daily (maximum 1.2 mg/day) 1, 3, 4
- Initiate with or just prior to starting urate-lowering therapy 1, 2, 3
Duration of prophylaxis:
- Minimum 6 months after starting urate-lowering therapy 1, 2
- OR 3 months after achieving target serum urate if no tophi present 1
- OR 6 months after achieving target serum urate if tophi are present 1
Familial Mediterranean Fever (FMF)
Adult dosing:
- 1.2-2.4 mg daily (given as single dose or divided twice daily) 2, 4
- Increase in 0.3 mg/day increments as needed to control disease 4
- Decrease in 0.3 mg/day increments if intolerable side effects develop 4
Pediatric FMF dosing (ages 4 and older):
- Ages 4-6 years: 0.3-1.8 mg daily 4
- Ages 6-12 years: 0.9-1.8 mg daily 4
- Ages >12 years: 1.2-2.4 mg daily 4
The minimal effective daily dose in adults is typically 1.0 mg/day, though this should be titrated based on response. 7
Dose Adjustments for Renal Impairment
Severe renal impairment (eGFR 15-29 mL/min/1.73 m²):
- Reduce prophylactic dose to 0.3 mg daily 1
- For acute gout: 0.6 mg × 1 dose only, no repeat for at least 2 weeks 1
Severe renal impairment (eGFR <30 mL/min/1.73 m²):
- Consider avoiding colchicine entirely and use alternative prophylaxis (low-dose NSAIDs with PPI or low-dose prednisone ≤10 mg/day) 1
Critical Drug Interactions Requiring Dose Reduction
Colchicine is CONTRAINDICATED with strong CYP3A4 or P-glycoprotein inhibitors in patients with renal or hepatic impairment. 3, 4
When coadministered with strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir, atazanavir, cyclosporine): 3, 4
- Prophylaxis: reduce to 0.3 mg once daily 4
- Acute gout: 0.6 mg × 1 dose, followed by 0.3 mg 1 hour later; no repeat for 3 days 4
- FMF: maximum 0.6 mg daily (may give as 0.3 mg twice daily) 4
Fatal colchicine toxicity has been reported with clarithromycin specifically. 4
Monitoring and Safety
Monitor for neurotoxicity and myotoxicity, especially in:
- Patients with renal impairment 1
- Concurrent statin therapy 1
- Age >75 years 8
- Patients on hemodialysis or with renal transplant 8
For long-term prophylactic use: Monitor creatine kinase (CK) and full blood count regularly. 8
Common Pitfalls to Avoid
- Do not use colchicine beyond 36 hours of symptom onset—it becomes ineffective 1, 2, 3
- Do not use the outdated high-dose regimen—it causes severe diarrhea without added benefit 5, 1, 3
- Do not stop prophylaxis prematurely—continue for full recommended duration based on tophi status 1
- Always calculate creatinine clearance before prescribing, especially in elderly patients 3, 8
- Do not ignore drug interactions—fatal toxicity can occur with CYP3A4 inhibitors 3, 4