Does Colchicine Eliminate Urate Crystals in Gout?
No, colchicine does not make urate crystals "go away" or dissolve them—it only treats the inflammatory response to crystals that are already present. 1, 2
Mechanism of Action: Anti-Inflammatory, Not Crystal-Dissolving
Colchicine works by disrupting the inflammatory cascade triggered by monosodium urate crystals, not by removing the crystals themselves. Specifically, it:
- Inhibits microtubule polymerization in neutrophils, preventing their activation, degranulation, and migration to the affected joint 2
- Interferes with inflammasome complex assembly in neutrophils and monocytes, blocking interleukin-1β activation 2
- Reduces the inflammatory response to crystals that remain physically present in the joint 1
The FDA drug label explicitly states that colchicine "disrupts cytoskeletal functions through inhibition of β-tubulin polymerization into microtubules, and consequently prevents the activation, degranulation and migration of neutrophils thought to mediate some gout symptoms"—not crystal dissolution. 2
Evidence for Efficacy in Symptom Relief (Not Crystal Removal)
High-strength evidence demonstrates colchicine reduces pain and inflammation during acute gout attacks, but this occurs through dampening the immune response to crystals:
- Colchicine reduces pain by 34% and clinical symptoms by 30% compared to placebo in acute gout, with a number needed to treat (NNT) of 3 for pain reduction 3, 4
- The American College of Rheumatology provides high-strength evidence that colchicine, NSAIDs, and corticosteroids all reduce symptoms in acute gout by treating inflammation, not by affecting crystal burden 1
- Treatment effectiveness depends on early initiation (within 12-36 hours of symptom onset), which reflects its anti-inflammatory mechanism rather than any crystal-dissolving properties 1, 5
What Actually Removes Crystals: Urate-Lowering Therapy
To actually reduce and eventually eliminate urate crystal deposits, you must lower serum urate levels below the saturation point (typically <6 mg/dL or 357 µmol/L):
- Only urate-lowering therapy (allopurinol, febuxostat) reduces crystal burden by decreasing serum urate levels, which allows existing crystals to gradually dissolve over months to years 1
- Moderate-strength evidence shows that after the initial period of increased flare risk, urate-lowering therapy reduces long-term risk for acute gout attacks by actually reducing crystal burden 1
- The American College of Physicians emphasizes that "symptoms result from an inflammatory reaction to the deposition of urate crystals, which occurs when the level of urate increases above its saturation point in the blood"—only lowering urate below this threshold removes crystals 1
Clinical Algorithm: Colchicine's Role in Gout Management
For acute gout flares:
- Use colchicine 1.2 mg at first sign of flare, followed by 0.6 mg one hour later, to treat inflammation 1, 5, 6
- Continue 0.6 mg once or twice daily until attack resolves 5, 6
- Understand this treats symptoms only—crystals remain 2
For crystal removal (long-term management):
- Initiate urate-lowering therapy (allopurinol or febuxostat) to actually dissolve crystals 1
- Use prophylactic low-dose colchicine (0.6 mg once or twice daily) for at least 6 months when starting urate-lowering therapy to prevent flares during the crystal dissolution process 1, 5
- Continue urate-lowering therapy indefinitely to maintain serum urate <6 mg/dL and prevent crystal reaccumulation 1
Common Pitfall to Avoid
Do not rely on colchicine alone for gout management. Patients often mistakenly believe that taking colchicine during flares is sufficient treatment. However, without urate-lowering therapy, crystals persist and accumulate, leading to progressively more frequent and severe attacks, chronic gouty arthritis, and tophus formation. 1 Colchicine treats the fire (inflammation), but urate-lowering therapy removes the fuel (crystals).