What is the recommended initial dose of colchicine (Colcrys) for an adult patient with normal renal function experiencing a gout flare?

Colchicine Dosing for Acute Gout Flare

For an adult patient with normal renal function experiencing an acute gout flare, administer colchicine 1.2 mg (two 0.6 mg tablets) immediately at the first sign of the flare, followed by 0.6 mg (one tablet) one hour later, for a total of 1.8 mg over one hour. 1

FDA-Approved Dosing Regimen

• The maximum recommended dose for treatment of gout flares is 1.8 mg over a one-hour period, and higher doses have not been found to be more effective 1
• This low-dose regimen (1.8 mg total) is as effective as the older high-dose regimen (4.8 mg over 6 hours) but with significantly fewer gastrointestinal side effects 2, 3

Critical Timing Considerations

• Start treatment within 12 hours of symptom onset for maximum efficacy, and no later than 36 hours after symptom onset 2, 3
• Colchicine effectiveness drops significantly beyond the 36-hour window 2, 3
• The American College of Rheumatology recommends a "pill in the pocket" approach for fully informed patients to self-medicate at the first warning symptoms 2

After Initial Loading Dose

• Wait 12 hours after the initial loading doses (1.2 mg + 0.6 mg), then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves 2, 1
• If the patient is already taking prophylactic colchicine when the attack occurs, take the loading dose as described above, then wait 12 hours before resuming the regular prophylactic dose 2, 1

Important Contraindications

• Colchicine is absolutely contraindicated in patients concurrently taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir) or P-glycoprotein inhibitors (cyclosporine) 2, 1
• Fatal colchicine toxicity has been reported with clarithromycin, a strong CYP3A4 inhibitor 1

Renal Function Considerations

• For patients with severe renal impairment (CrCl <30 mL/min or eGFR <30 mL/min), colchicine should be avoided and alternative therapy strongly considered 4, 2, 3
• For patients with moderate renal impairment (CrCl 30-50 mL/min), close monitoring for adverse effects is required 3
• The FDA-approved dosing of 1.2 mg followed by 0.6 mg one hour later applies specifically to patients with normal renal function 4

Alternative Options When Colchicine is Contraindicated

• Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days) are highly effective alternatives when colchicine cannot be used 2, 3
• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution are another option, though they should be avoided in severe renal impairment 2, 3
• Intra-articular corticosteroid injection is an excellent option for monoarticular gout 2, 3

Common Pitfalls to Avoid

• Never use the outdated high-dose regimen of 0.5 mg every 2 hours until relief or toxicity, which causes severe diarrhea in most patients without additional benefit 2, 3
• Do not prescribe doses exceeding 1.8 mg in the first hour, as this provides no additional benefit but substantially increases gastrointestinal toxicity 2
• Do not delay treatment beyond 12-36 hours after symptom onset, as effectiveness decreases significantly 2, 3

Evidence Quality

• The low-dose regimen is supported by the AGREE trial, which demonstrated equal efficacy to high-dose colchicine for pain reduction at 24 hours, with a number needed to treat (NNT) of 5 for achieving 50% or greater pain reduction 2
• This dosing regimen is endorsed by the American College of Rheumatology, European League Against Rheumatism, and FDA drug labeling 4, 2, 1