What is the recommended colchicine (Colchicine) regimen for an adult patient with acute gout attack, considering potential kidney or liver disease?

Colchicine Regimen for Acute Gout Attack

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, with critical dose adjustments required for renal impairment (avoid if eGFR <30 mL/min) and absolute contraindication with strong CYP3A4/P-glycoprotein inhibitors. 1, 2, 3

Critical Timing Window

• Start treatment within 36 hours of symptom onset—colchicine effectiveness drops significantly beyond this timeframe, with optimal efficacy when initiated within 12 hours. 1, 2
• Do not use colchicine if the attack began more than 36 hours prior to presentation. 1, 2

Standard Dosing for Normal Renal Function

• Loading dose: 1.2 mg (two 0.6 mg tablets) at first sign of flare, followed by 0.6 mg one hour later. 1, 3
• Maximum acute dose: 1.8 mg total over the first hour—higher doses provide no additional benefit but substantially increase gastrointestinal toxicity. 1, 3
• Continuation: After 12 hours from the initial loading doses, resume 0.6 mg once or twice daily until complete resolution of the attack. 1, 2, 3

Dose Adjustments for Renal Impairment

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

• Use the standard loading dose (1.2 mg followed by 0.6 mg one hour later) with close monitoring for adverse effects. 2, 3
• After 12 hours, continue with 0.6 mg once daily (rather than twice daily) until attack resolves. 2

Severe Renal Impairment (eGFR 15-29 mL/min)

• Reduce to single dose: 0.6 mg once only—do not repeat the second 0.6 mg dose. 2, 3
• Do not repeat treatment course for at least 2 weeks. 3
• Consider alternative therapy (corticosteroids) as first-line instead. 2

End-Stage Renal Disease (eGFR <15 mL/min or on dialysis)

• Maximum dose: 0.6 mg as a single dose only. 3
• Do not repeat for at least 2 weeks. 3
• Strongly consider corticosteroids as preferred first-line therapy (prednisone 30-35 mg daily for 3-5 days). 1, 2

Absolute Contraindications

• Concurrent use of strong CYP3A4 inhibitors: clarithromycin, erythromycin, ketoconazole, itraconazole, ritonavir, atazanavir, indinavir. 1, 2, 3
• Concurrent use of strong P-glycoprotein inhibitors: cyclosporine, ranolazine. 1, 3
• Combined renal AND hepatic impairment in patients taking any CYP3A4 or P-glycoprotein inhibitors. 1, 3
• Severe renal impairment (eGFR <30 mL/min) is a relative contraindication—use only with extreme caution and dose reduction, or preferably avoid entirely. 1, 2

Dose Adjustments for Drug Interactions

With Strong CYP3A4 or P-gp Inhibitors (if unavoidable)

• Acute treatment: 0.6 mg once, followed by 0.3 mg one hour later—do not repeat for at least 3 days. 3
• If patient has ANY renal or hepatic impairment: Do not give colchicine at all. 3

With Moderate CYP3A4 Inhibitors (diltiazem, verapamil, fluconazole, grapefruit juice)

• Acute treatment: 1.2 mg once only—do not give the second 0.6 mg dose, and do not repeat for at least 3 days. 3

Hepatic Impairment Considerations

• Mild to moderate hepatic impairment: Use standard dosing with close monitoring. 3
• Severe hepatic impairment: Reduce dose and consider alternative therapy. 3
• Combined hepatic and renal impairment: Colchicine is contraindicated if patient is also taking CYP3A4/P-gp inhibitors. 3

If Patient Already on Prophylactic Colchicine

• Give the full loading dose (1.2 mg followed by 0.6 mg one hour later) at first sign of acute flare. 1, 3
• Wait 12 hours after the loading doses, then resume the regular prophylactic dose (0.6 mg once or twice daily). 1, 3

Alternative Therapies When Colchicine is Contraindicated

• Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days, then stop or taper over 7-10 days. 1, 2
• NSAIDs: Full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution—but avoid in severe renal impairment (eGFR <30 mL/min). 1
• Intra-articular corticosteroid injection: Excellent option for monoarticular or oligoarticular involvement of accessible large joints. 4, 1

Common Pitfalls to Avoid

• Do not use the obsolete high-dose regimen (0.5 mg every 2 hours until relief or diarrhea)—this causes severe gastrointestinal toxicity in most patients with no additional benefit. 4, 1
• Do not delay treatment beyond 36 hours of symptom onset—effectiveness drops dramatically. 1, 2
• Do not ignore drug interactions—fatal colchicine toxicity has been reported with clarithromycin and cyclosporine. 1, 3
• Do not use standard doses in severe renal impairment—colchicine clearance is reduced by 75% in end-stage renal disease. 3
• Do not combine NSAIDs with systemic corticosteroids—synergistic gastrointestinal toxicity. 1

Evidence Quality

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) for achieving ≥50% pain reduction at 24 hours (NNT = 5), but with significantly fewer gastrointestinal adverse events. 1 This regimen is endorsed by the American College of Rheumatology, European League Against Rheumatism, and FDA drug labeling. 1, 2, 3