What is the recommended dosage and treatment duration of colchicine 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 tablets) 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

Initial Treatment Regimen

• Start treatment immediately at the first sign of a gout flare—ideally within 12 hours of symptom onset, and no later than 36 hours, as efficacy drops significantly beyond this window 2, 1
• The loading dose is 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg) 1
• 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 2, 3
• Higher doses provide no additional benefit and substantially increase toxicity 2

Continuation After Initial Dosing

• Wait 12 hours after the initial loading doses, then resume colchicine at 0.6 mg once or twice daily until the acute attack completely resolves 2, 1
• Continue this prophylactic dosing typically for a few days until symptoms resolve 2
• If the patient was already taking prophylactic colchicine when the flare occurred, give the loading dose as above, wait 12 hours, then resume the regular prophylactic dose 2, 1

Treatment Duration

• Continue colchicine at the prophylactic dose (0.6 mg once or twice daily) until the gouty attack has completely resolved 2
• The typical duration is several days, but this depends on clinical response 2
• Do not repeat the loading dose regimen for at least 3 days 1

Critical Contraindications

Absolute contraindications (do not use colchicine):

• Concurrent use of strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, atazanavir, indinavir, itraconazole, nefazodone) 2, 1
• Concurrent use of P-glycoprotein inhibitors (cyclosporine) 2, 1
• Severe renal impairment (GFR <30 mL/min or CrCl <30 mL/min) 2, 1
• Patients with both renal or hepatic impairment AND taking potent CYP3A4 or P-glycoprotein inhibitors 2

Alternative Treatment Options if Colchicine is Contraindicated

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 4, 2
• Oral corticosteroids: 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 4, 2
• Intra-articular corticosteroid injection for monoarticular gout 2

Evidence Quality and Rationale

• The low-dose regimen (1.8 mg total) is supported by moderate-quality evidence from the AGREE trial 2, 5
• This regimen achieved 50% or greater pain reduction at 24 hours with a number needed to treat (NNT) of 5 2
• Treatment success occurred in 418 per 1000 patients with low-dose colchicine versus 172 per 1000 with placebo (RR 2.43) 3
• The incidence of adverse events with low-dose colchicine (364 per 1000) was similar to placebo (276 per 1000) 3

Common Pitfalls to Avoid

• Do not use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or toxicity), which causes severe diarrhea in most patients and provides no additional benefit 2
• Do not delay treatment beyond 36 hours of symptom onset, as effectiveness drops significantly 2, 1
• Do not prescribe colchicine without checking renal function and medication interactions, as this is a common source of toxicity in real-world practice 6
• Do not exceed 1.8 mg in the first hour, as higher doses increase gastrointestinal toxicity without improving efficacy 2, 1