What is the recommended initial dose of colchicine (Colcrys) for an adult patient with acute gout and potential kidney impairment?

Colchicine Dosing for 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 over one hour), then continue 0.6 mg once or twice daily until the attack resolves—but only if treatment starts within 36 hours of symptom onset. 1, 2, 3, 4

Critical Timing Requirement

• Treatment must begin within 36 hours of symptom onset; effectiveness drops significantly beyond this window, making colchicine inappropriate for delayed presentations 1, 2, 3
• Optimal efficacy occurs when started within 12 hours of the first symptoms 1
• Consider a "pill in the pocket" approach for well-informed patients to self-medicate at the earliest warning signs 1

Standard Dosing Algorithm

Initial loading dose:

• 1.2 mg (two 0.6 mg tablets) immediately at flare onset 1, 2, 3, 4
• Followed by 0.6 mg (one tablet) exactly one hour later 1, 2, 3, 4
• Total loading dose: 1.8 mg over one hour 1, 2, 3

Continuation dosing:

• Wait 12 hours after the loading doses 1, 2
• Resume 0.6 mg once or twice daily until complete attack resolution 1, 2, 3
• Maximum daily dose for prophylaxis: 1.2 mg/day 2, 3, 4

Dose Adjustments for Kidney Impairment

Mild to moderate renal impairment (eGFR 30-80 mL/min):

• Use standard loading dose (1.2 mg followed by 0.6 mg one hour later) 2, 4
• Monitor closely for adverse effects 2, 4
• Treatment courses should not be repeated more than once every two weeks in severe impairment (eGFR <30 mL/min) 4

Severe renal impairment (eGFR <30 mL/min):

• Strongly consider alternative therapy first (corticosteroids preferred) 1, 2
• If colchicine must be used: single dose of 0.6 mg only 4
• Do not repeat treatment for at least two weeks 4

Dialysis patients:

• Single dose of 0.6 mg maximum 4
• Do not repeat for at least two weeks 4

Absolute Contraindications

Do not use colchicine if the patient is taking: 1, 2, 4

• Strong CYP3A4 inhibitors: clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir
• P-glycoprotein inhibitors: cyclosporine, verapamil
• This combination dramatically increases colchicine plasma levels and risk of fatal toxicity 1, 2

Additional contraindications:

• Severe renal impairment (eGFR <30 mL/min) combined with any CYP3A4 or P-gp inhibitor use 1, 2
• Patients with both renal AND hepatic impairment taking these interacting drugs 1

Alternative Treatment Options When Colchicine Cannot Be Used

First-line alternatives: 1, 2

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, sulindac) until complete resolution 1
• Oral corticosteroids: prednisone 30-35 mg daily for 3-5 days, or 0.5 mg/kg/day for 5-10 days 1, 2
• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement 1, 2

Evidence Quality and Rationale

• The low-dose regimen (1.8 mg total) is supported by the AGREE trial, which demonstrated equal efficacy to high-dose colchicine (4.8 mg) with significantly fewer gastrointestinal side effects 1, 5, 6
• Number needed to treat (NNT) is 5 for achieving ≥50% pain reduction at 24 hours 1
• The older high-dose regimen (0.5 mg every 2 hours until relief or toxicity) is obsolete and causes severe diarrhea in most patients 1, 7

Common Pitfalls to Avoid

• Never exceed 1.8 mg in the first hour—higher doses provide no additional benefit but substantially increase gastrointestinal toxicity 1, 5, 6
• Do not use colchicine for delayed presentations (>36 hours after onset) 1, 2, 3
• Always calculate eGFR before prescribing to identify patients requiring dose adjustment or alternative therapy 2
• Screen for drug interactions with CYP3A4/P-gp inhibitors before prescribing 1, 2, 4
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1

Special Consideration: Patients Already on Prophylactic Colchicine

• If already taking prophylactic colchicine (0.6 mg once or twice daily) when a flare occurs, give the full loading dose (1.2 mg followed by 0.6 mg one hour later) 1, 4
• Wait 12 hours after loading doses, then resume the regular prophylactic dose 1, 4