Colchicine Dosing for Acute Gout Flare
For this 53-year-old male experiencing an acute gout flare while on maintenance allopurinol, 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
Acute Treatment Protocol
- Initiate treatment within 36 hours of symptom onset (ideally within 12 hours) for optimal effectiveness, as efficacy drops significantly beyond this timeframe 2, 3
- The loading dose consists of 1.2 mg followed by 0.6 mg one hour later, which is as effective as older high-dose regimens but with significantly fewer gastrointestinal side effects 2, 3, 4
- After the initial loading doses, wait 12 hours, then resume the prophylactic dose of 0.6 mg once or twice daily until the acute attack completely resolves 3, 1
Critical Safety Considerations
Before prescribing, verify the following:
- Renal function: Colchicine should be avoided in severe renal impairment (CrCl <30 mL/min or eGFR <30 mL/min) 2, 3
- Drug interactions: Colchicine is absolutely contraindicated with strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir) due to risk of fatal toxicity 2, 1
- Hepatic impairment: Combined hepatic and renal impairment with concurrent use of CYP3A4/P-gp inhibitors is an absolute contraindication 3, 1
Continuation of Allopurinol
Continue the patient's scheduled allopurinol 100 mg daily without interruption during the acute flare. 5, 6
- Multiple randomized controlled trials demonstrate that continuing or initiating allopurinol during an acute gout attack does not prolong the attack or worsen pain when appropriate anti-inflammatory prophylaxis is used 5, 6
- The 2020 American College of Rheumatology guidelines support starting or continuing urate-lowering therapy during acute flares 2
Alternative Treatment Options
If colchicine is contraindicated or not tolerated, consider:
- Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days 2, 3, 7
- NSAIDs: Full FDA-approved doses (naproxen 500 mg twice daily or indomethacin 50 mg three times daily) until complete resolution, but avoid in severe renal impairment 2, 3, 7
- Intra-articular corticosteroid injection: Excellent option for monoarticular involvement 2, 3, 7
Common Pitfalls to Avoid
- Never use the obsolete high-dose colchicine regimen (0.5 mg every 2 hours until relief or toxicity), which causes severe diarrhea in most patients without additional benefit 3, 7
- Do not exceed 1.8 mg total dose in the first hour, as higher doses provide no additional efficacy but substantially increase gastrointestinal toxicity 3, 7
- Do not delay treatment beyond 36 hours of symptom onset, as effectiveness drops significantly 3, 7
- Monitor closely if patient is on statins, as the combination with colchicine increases risk of myopathy and neuromuscular toxicity, especially with any degree of renal impairment 2, 7
Long-Term Prophylaxis Considerations
Since this patient is on scheduled allopurinol, ensure he is receiving appropriate flare prophylaxis:
- Standard prophylaxis is colchicine 0.6 mg once or twice daily (maximum 1.2 mg/day) for at least 6 months after initiating or adjusting urate-lowering therapy 2, 7
- Prophylaxis should continue for at least 3 months after achieving target serum urate if no tophi are present, or 6 months if tophi are present 2, 3