What is the recommended dose of colchicine (Colchicine) for acute gout attacks and prophylaxis?

Colchicine Dosing for Acute Gout and Prophylaxis

For acute gout flares, administer colchicine 1.2 mg at the first sign of symptoms followed by 0.6 mg one hour later (total 1.8 mg), but only if treatment can be initiated within 36 hours of symptom onset; for prophylaxis, use 0.6 mg once or twice daily starting with urate-lowering therapy and continuing for at least 6 months. 1, 2

Acute Gout Treatment Regimen

Standard Dosing

• The FDA-approved regimen is 1.2 mg at the first sign of flare, followed by 0.6 mg one hour later (maximum 1.8 mg total over one hour). 2, 1
• This low-dose regimen is as effective as higher doses with significantly fewer gastrointestinal side effects. 1, 3
• Treatment must be initiated within 36 hours of symptom onset—delaying beyond this window dramatically reduces effectiveness and is not recommended. 4, 1, 5

Continuation After Initial Doses

• After the initial 1.8 mg loading doses, wait 12 hours, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves. 4, 1
• If a patient is already on prophylactic colchicine when a flare occurs, give the 1.2 mg + 0.6 mg regimen, wait 12 hours, then resume the prophylactic dose. 4, 2

Critical Timing Consideration

• Colchicine should only be used for gout attacks with onset within the previous 36 hours, as effectiveness significantly decreases beyond this timeframe. 1, 5, 6
• Pharmacologic treatment should be initiated within 24 hours of acute gout attack onset for optimal results. 4

Prophylaxis Dosing

Standard Regimen

• The recommended dose for gout flare prophylaxis is 0.6 mg once or twice daily, with a maximum daily dose of 1.2 mg/day. 1, 2
• This represents first-line prophylaxis with Level A evidence from the American College of Rheumatology. 1

When to Initiate

• Start prophylaxis with or just prior to initiating urate-lowering therapy (allopurinol, febuxostat, or pegloticase). 1, 2
• An increase in gout flares commonly occurs after starting uric acid-lowering therapy due to mobilization of urate from tissue deposits. 2

Duration of Prophylaxis

• Continue prophylaxis for at least 6 months from initiation of urate-lowering therapy. 1, 2
• More specifically, continue for the greater of: at least 6 months OR 3 months after achieving target serum urate if no tophi are detected on physical exam. 4, 1
• If tophi are present, continue for 6 months after achieving target serum urate. 1

Common Pitfall to Avoid

• Do not stop prophylaxis too early—premature discontinuation leads to increased flare rates during urate-lowering therapy. 1, 6

Dose Adjustments for Renal Impairment

Severe Renal Impairment (eGFR <30 mL/min)

• Reduce the dose to a single 0.6 mg dose with no repeat treatment for at least two weeks. 1, 5, 6
• For patients on dialysis, administer a single 0.6 mg dose and do not repeat before two weeks. 5
• Consider glucocorticoids as the preferred first-line treatment over colchicine in this population. 5

Moderate Renal Impairment (eGFR 30-60 mL/min)

• Standard dosing may be used with caution and close monitoring for toxicity. 6

eGFR 15-29 mL/min

• Reduce prophylactic dose to 0.3 mg daily. 1

Critical Drug Interactions

Absolute Contraindications

• Colchicine is absolutely contraindicated with strong CYP3A4 and/or P-glycoprotein inhibitors due to risk of life-threatening toxicity. 5, 6, 2
• Major interactions requiring avoidance include: clarithromycin, erythromycin, cyclosporine, ketoconazole, itraconazole, ritonavir/nirmatrelvir (Paxlovid), verapamil, and diltiazem. 1, 5

Moderate Inhibitors

• When moderate CYP3A4/P-gp inhibitors cannot be avoided, reduce the colchicine dose by 50% or more. 6, 2
• Screen for drug interactions with CYP3A4/P-glycoprotein inhibitors before prescribing. 5

Alternative Treatment Options

When Colchicine is Contraindicated for Acute Flares

• NSAIDs at full FDA-approved doses (e.g., naproxen, indomethacin, sulindac) until complete resolution of the attack. 4, 5
• Oral prednisone 0.5 mg/kg/day for 5-10 days at full dose, then stop or taper over 7-10 days. 4, 5
• Intra-articular corticosteroid injection (dose varies by joint size) for involvement of 1-2 large joints. 4, 5

Alternative Prophylaxis Options

• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with proton pump inhibitor where indicated. 4, 1
• Low-dose prednisone or prednisolone (<10 mg/day) as second-line if colchicine and NSAIDs are contraindicated, not tolerated, or ineffective. 4, 1
• Do not use high-dose corticosteroids (>10 mg/day) for prophylaxis—this carries significant long-term risks. 1

Key Clinical Pearls

Monitoring Requirements

• Monitor patients on colchicine prophylaxis for neurotoxicity and myotoxicity, especially in those with renal impairment or concurrent statin therapy. 1
• Calculate eGFR immediately when considering colchicine for acute gout. 5

What NOT to Do

• Do not use colchicine as an analgesic for pain from other causes—it is not an analgesic medication. 2
• Do not use high-dose colchicine regimens for acute gout—they increase toxicity without improving efficacy. 6, 7
• Do not interrupt ongoing urate-lowering therapy during an acute gout attack. 4

Combination Therapy Considerations

• For severe acute gout with multiple large joints involved or inadequate response to monotherapy, combination therapy may be considered using full doses of colchicine plus NSAIDs, oral corticosteroids plus colchicine, or intra-articular steroids with any other modality. 6