What is the recommended dose of colchicine for an adult patient with acute gout flare and normal renal function?

Colchicine Dosing for Acute Gout Flare

For an adult patient with normal renal function experiencing an acute gout flare, 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 (beginning 12 hours after initial doses) until the attack resolves. 1, 2, 3, 4

Critical Timing Requirements

• Treatment must be initiated within 36 hours of symptom onset - effectiveness drops significantly beyond this window, with optimal efficacy achieved when started within 12 hours 1, 2, 3
• Educate patients to use a "pill in the pocket" approach, self-medicating at the first warning symptoms for maximum benefit 2
• Do not initiate colchicine if the flare began more than 36 hours prior, as it will be ineffective 1, 3

FDA-Approved Dosing Regimen

• Initial loading dose: 1.2 mg (two 0.6 mg tablets) at first sign of flare 4
• Second dose: 0.6 mg (one tablet) exactly one hour after the initial dose 4
• Maximum acute treatment dose: 1.8 mg total over one hour - higher doses provide no additional benefit but substantially increase gastrointestinal toxicity 1, 4
• Continuation dosing: Wait 12 hours after the loading doses, then resume 0.6 mg once or twice daily until complete resolution of the attack 1, 3, 4

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg) for achieving ≥50% pain reduction at 24 hours, with a number needed to treat of 5 1, 2
• The low-dose regimen causes significantly fewer gastrointestinal adverse events compared to older high-dose protocols 1, 5
• The obsolete regimen of 0.5 mg every 2 hours until relief or toxicity causes severe diarrhea in most patients and should never be used 1

Absolute Contraindications

• Concurrent use of strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, ritonavir) - this combination dramatically increases colchicine plasma concentrations and risk of fatal toxicity 1, 2, 3, 6
• Severe renal impairment (eGFR <30 mL/min) - colchicine should be avoided entirely in this population 1, 2, 3
• Patients with both renal or hepatic impairment AND taking potent CYP3A4/P-gp inhibitors must never receive colchicine 1

Alternative Treatment Options When Colchicine is Contraindicated

• Oral corticosteroids: Prednisone 30-35 mg daily for 3-5 days, or prednisone 0.5 mg/kg/day for 5-10 days then stop or taper over 7-10 days 1, 2, 3
• NSAIDs: Full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution - but avoid in severe renal impairment, heart failure, or cirrhosis 1, 2, 3
• Intra-articular corticosteroid injection: Excellent option for monoarticular or oligoarticular involvement of accessible large joints 1, 3

Special Considerations for Patients Already on Prophylactic Colchicine

• If the patient is already taking prophylactic colchicine when the acute flare occurs, still administer the full loading dose (1.2 mg followed by 0.6 mg one hour later) 1, 4
• Wait 12 hours after the loading doses before resuming the regular prophylactic dose 1, 4

Common Pitfalls to Avoid

• Never exceed 1.8 mg total in the first hour - higher doses provide no additional benefit and substantially increase toxicity 1, 4
• Never use colchicine beyond 36 hours after symptom onset - it becomes ineffective and only exposes patients to unnecessary side effects 1, 2, 3
• Always calculate eGFR before prescribing - renal impairment dramatically increases toxicity risk 3, 7
• Always screen for drug interactions with CYP3A4/P-gp inhibitors before prescribing colchicine 1, 2, 3, 6
• Real-world data shows physicians frequently prescribe excessive doses (mean 2.8 mg in first 24 hours) and fail to adjust for renal impairment - avoid this dangerous practice 7

Combination Therapy for Severe Attacks

• For severe acute gout with polyarticular involvement or multiple large joints, initial combination therapy with colchicine plus NSAIDs is appropriate 1
• Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 1
• Acceptable combinations include: colchicine + NSAIDs, oral corticosteroids + colchicine, or intra-articular steroids + any oral modality 1