What is the recommended treatment for an adult patient with a history of gout (hyperuricemia) experiencing an acute gout attack, considering the use of colchicine?

Colchicine for Gout

Acute Gout Flare Treatment

For an acute gout attack, administer colchicine 1.2 mg at the first sign of flare, followed by 0.6 mg one hour later (total 1.8 mg over one hour), then continue 0.6 mg once or twice daily until the attack resolves. 1

Critical Timing Considerations

• Start treatment within 36 hours of symptom onset—colchicine effectiveness drops significantly beyond this window, with optimal efficacy when initiated within 12 hours. 2
• The FDA-approved low-dose regimen (1.8 mg total in first hour) is equally effective as the older high-dose regimen (4.8 mg over 6 hours) but causes significantly fewer gastrointestinal adverse events. 3, 2
• High-strength evidence from 28 trials demonstrates that colchicine reduces pain in acute gout attacks. 3

Dosing Algorithm

Initial treatment:

• 1.2 mg (two 0.6 mg tablets) immediately at first symptom
• Followed by 0.6 mg (one tablet) exactly one hour later
• Maximum dose for acute treatment: 1.8 mg over one hour 1

Continuation phase:

• Wait 12 hours after the loading doses
• Resume 0.6 mg once or twice daily until complete resolution 2, 1
• If already taking prophylactic colchicine when the attack occurs, take the loading dose, then wait 12 hours before resuming regular prophylactic dosing 2

Prophylaxis of Gout Flares

For prophylaxis, use colchicine 0.6 mg once or twice daily (maximum 1.2 mg/day). 1

• High-strength evidence shows prophylactic colchicine reduces the risk of acute gout attacks by at least half in patients starting urate-lowering therapy. 3
• Continue prophylaxis for at least 6 months when initiating urate-lowering therapy (allopurinol, febuxostat, or pegloticase), as mobilization of urate from tissue deposits increases flare risk. 1
• Moderate-strength evidence indicates prophylaxis duration should exceed 8 weeks. 3

Absolute Contraindications

Do not prescribe colchicine in these situations:

• Patients taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole, ritonavir) or P-glycoprotein inhibitors (cyclosporine) 2, 1
• Severe renal impairment (GFR <30 mL/min or CrCl <30 mL/min) 2
• Combined hepatic and renal impairment with concurrent use of potent CYP3A4 or P-glycoprotein inhibitors 2

Alternative Treatment Options When Colchicine is Contraindicated

NSAIDs (first alternative):

• Use full FDA-approved doses of naproxen, indomethacin, or sulindac until complete attack resolution 3, 2
• No evidence suggests one NSAID is superior to another for gout treatment 2
• Caution: Avoid in patients with renal disease, heart failure, cirrhosis, or history of gastrointestinal bleeding 2

Corticosteroids (second alternative):

• Oral prednisone 30-35 mg/day for 3-5 days, or 0.5 mg/kg/day for 5-10 days with taper over 7-10 days 2
• Intra-articular corticosteroid injection is excellent for monoarticular gout 2
• Highly effective when both colchicine and NSAIDs are contraindicated 3, 2

Combination Therapy for Severe Attacks

For severe gout attacks involving multiple large joints or polyarticular arthritis, use combination therapy with colchicine AND NSAIDs. 2

• This provides synergistic anti-inflammatory effects through different pathways 2
• Critical safety check: Assess renal function before prescribing—both agents should be avoided if GFR <30 mL/min 2
• Be aware of potential synergistic gastrointestinal toxicity when combining NSAIDs with systemic corticosteroids 2

Common Pitfalls to Avoid

• Never use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or toxicity)—this causes severe diarrhea in most patients with no additional benefit 2
• Do not delay treatment beyond 12-36 hours after symptom onset, as effectiveness significantly decreases 2
• Do not use colchicine as an analgesic for pain from other causes—it is specific for gout 1
• Do not exceed 1.8 mg in the first hour for acute treatment—higher doses provide no additional efficacy but substantially increase toxicity 2

Special Populations

Pediatric patients:

• Colchicine is not recommended for prophylaxis or treatment of gout flares in children 1
• For familial Mediterranean fever in children ≥4 years, dosing is weight-based (0.3-1.8 mg daily depending on age) 1

Patients with NSAID allergies:

• Colchicine can be safely used—it works through a different mechanism (microtubule polymerization inhibition) with no cross-reactivity to NSAIDs 2