What is the recommended dosage regimen for Colchicine (colchicine) in an adult patient with acute gout?

Recommended Colchicine Dosing for Acute Gout

The regimen you described is incorrect and potentially dangerous—do not use it. The evidence-based approach is: 1.2 mg (two 0.6 mg tablets) at the first sign of flare, followed by 0.6 mg (one tablet) one hour later, then wait 12 hours before resuming prophylactic dosing of 0.6 mg once or twice daily until the attack completely resolves. 1, 2, 3

Critical Problems with the Proposed Regimen

• The "2 tablets now and 1 tablet after one hour" totals 1.8 mg over one hour, which exceeds the FDA-approved maximum of 1.8 mg by giving an additional dose after the initial loading. The correct dosing is 1.2 mg followed by 0.6 mg one hour later (total 1.8 mg), not 1.0 mg followed by 0.5 mg. 3

• There is no evidence supporting the tapering schedule you described (twice daily for 3 days, then once daily for 3 days). After the loading dose, wait 12 hours, then resume 0.6 mg once or twice daily until the attack fully resolves—this is symptom-driven, not a fixed duration. 1, 2, 3

Evidence-Based Dosing Algorithm

Initial Loading Dose (Day 1)

• Give 1.2 mg (two 0.6 mg tablets) at the first sign of symptoms, followed by 0.6 mg (one tablet) exactly one hour later. 1, 3
• This totals 1.8 mg over one hour—the maximum FDA-approved dose for acute treatment. 3
• Treatment must start within 36 hours of symptom onset; effectiveness drops significantly beyond this window. 1, 2

After Loading Dose

• Wait 12 hours after the second dose (the 0.6 mg dose given one hour after the initial 1.2 mg). 2, 3
• Then resume prophylactic dosing of 0.6 mg once or twice daily (maximum 1.2 mg/day). 1, 3

Duration of Treatment

• Continue 0.6 mg once or twice daily until the acute attack completely resolves—this is symptom-driven, not a predetermined number of days. 2, 4
• Most attacks resolve within a few days, but continue treatment until symptoms are gone. 2

Critical Safety Considerations

Absolute Contraindications

• Do not give colchicine to patients taking strong CYP3A4 inhibitors (clarithromycin, erythromycin, ketoconazole) or P-glycoprotein inhibitors (cyclosporine, ritonavir), especially if they have any renal or hepatic impairment. 1, 2, 4

Renal Impairment

• Avoid colchicine entirely in severe renal impairment (CrCl or eGFR <30 mL/min)—use alternative therapy instead. 2, 4
• Always calculate creatinine clearance before prescribing, especially in elderly patients. 1

Drug Interactions Requiring Dose Reduction

• Significant dose reductions are mandatory when used with moderate CYP3A4 inhibitors (diltiazem, verapamil, azole antifungals). 1

Why Low-Dose Colchicine is Preferred

• The low-dose regimen (1.8 mg total) is equally effective as the outdated high-dose regimen (4.8 mg over 6 hours) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat of 5. 2, 4, 5
• High-dose regimens cause severe diarrhea in most patients with no additional benefit—the old regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete. 2, 6

Alternative Options if Colchicine Cannot Be Used

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution. 2, 4
• Oral corticosteroids (prednisone 30-35 mg/day for 3-5 days, or 0.5 mg/kg/day for 5-10 days). 2, 4
• Intra-articular corticosteroid injection for monoarticular gout. 2

Common Pitfalls to Avoid

• Do not delay treatment beyond 36 hours—colchicine is most effective within 12 hours of symptom onset. 1, 2
• Do not use arbitrary tapering schedules—continue treatment until symptoms resolve completely. 2, 4
• Do not combine NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity. 2, 4
• Do not ignore renal function—always calculate CrCl before prescribing. 1, 2