What is the recommended dosing of colchicine for an adult patient with acute gout flare and potential impaired renal function?

Colchicine Dosing in Acute Gout

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), then continue 0.6 mg once or twice daily until the attack resolves—but in patients with severe renal impairment (CrCl <30 mL/min), reduce to a single 0.6 mg dose and do not repeat for at least two weeks. 1, 2

Standard Dosing for Normal Renal Function

• The FDA-approved regimen is 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg (one tablet) one hour later, for a total of 1.8 mg over one hour 2
• This low-dose regimen is as effective as the older high-dose regimen (4.8 mg over 6 hours) but with significantly fewer gastrointestinal side effects 1, 3
• After the initial loading doses, wait 12 hours, then resume prophylactic dosing of 0.6 mg once or twice daily until the acute attack completely resolves 1, 2
• Treatment must be initiated within 36 hours of symptom onset for optimal effectiveness, ideally within 12 hours 1

Critical Dosing Adjustments for Renal Impairment

Mild to Moderate Renal Impairment (CrCl 30-80 mL/min)

• No dose adjustment required for the acute treatment regimen (1.2 mg followed by 0.6 mg one hour later) 2
• Monitor closely for adverse effects, particularly gastrointestinal symptoms 2

Severe Renal Impairment (CrCl <30 mL/min)

• Reduce the acute treatment dose to a single 0.6 mg dose only 2
• Do not repeat the treatment course more than once every two weeks 2
• Recent evidence suggests that carefully monitored doses of ≤0.5 mg/day can be effective and well-tolerated in severe CKD, with 83% efficacy and 77% tolerability in hospitalized patients 4

Dialysis Patients

• Administer only 0.6 mg as a single dose for acute flares 2
• Do not repeat more than once every two weeks 2
• For prophylaxis in dialysis patients, use 0.3 mg twice weekly 2

Absolute Contraindications

Do NOT prescribe colchicine to patients with renal OR hepatic impairment who are taking strong CYP3A4 or P-glycoprotein inhibitors 1, 5, 2:

• Clarithromycin, erythromycin
• Cyclosporine, tacrolimus
• Ketoconazole, itraconazole
• Ritonavir and other protease inhibitors
• Fatal colchicine toxicity has been reported with these combinations 5, 6

Alternative Treatment Options When Colchicine is Contraindicated

• Oral corticosteroids: prednisone 30-35 mg daily for 3-5 days 1, 5
• NSAIDs at full FDA-approved doses (naproxen 500 mg twice daily, indomethacin 50 mg three times daily) until attack resolves, but avoid in severe renal impairment (CrCl <30 mL/min) 1
• Intra-articular corticosteroid injection for monoarticular gout 7, 1

Common Pitfalls to Avoid

• The older high-dose regimen (0.5 mg every 2 hours until relief or diarrhea) is obsolete and causes severe diarrhea in most patients—never use this approach 7, 1
• Do not treat acute flares with colchicine in patients already on prophylactic colchicine who also have severe renal impairment 2
• Do not exceed 1.8 mg total dose in the first hour—higher doses provide no additional benefit but substantially increase toxicity 1
• Patients on statins with renal impairment are at particularly high risk for colchicine-induced myopathy and neuromuscular toxicity 5, 6
• Treatment delayed beyond 36 hours has significantly reduced effectiveness 1

Prophylactic Dosing Context

• For prophylaxis during urate-lowering therapy initiation, use 0.6 mg once or twice daily (maximum 1.2 mg/day) for at least 6 months 1, 2
• In severe renal impairment, reduce prophylactic dose to 0.3 mg daily or 0.3 mg every other day 2, 8