- Terminating attacks of gout as soon as possible
- Preventing the recurrence of flares
- Preventing and reversing complications
Colchicine. Colchicine is effective in terminating an acute attack if administered within 12 hours of symptom onset. However, it is an even better prophylactic agent against gout flares. A recent randomized controlled trial had compared the efficacy of low-dose colchicine (1.8 mg/day) versus the more popularly used high-dose colchicine (4.8 mg/day – given as a 1.2 mg initial dose followed by 0.6 mg every 2 hours until either the attack stops or the patient develops toxicity to diarrhea). The study found that the low-dose schedule is as effective as the high dose administration of the drug but with a safety profile comparable to placebo. This should discourage doctors from using high-doses of colchicine since, most of the time, patients develop toxicity (diarrhea in particular) before the arthritis gets better. For prophylaxis, standard doses of the drug are within the 0.6 – 1.8 mg/day range.
No dose adjustments in colchicine is warranted if Creatinine Clearance (Cr Cl) is >50ml/min. However, the maximum dose of colchicine is 0.6 mg/day if CrCl is 35-49ml/min and 0.6mg every 2-3 days if CrCl is 10-34ml/min, Colchicine should be avoided in patients with CrCl <10ml/min and in patients undergoing hemodialysis. The drug is non-dialyzable and continued use predisposes to toxicity. Other contra-indications are significant liver disease and combined liver and renal Some authors recommend monitoring muscle enzymes if we decide to give colchicine in patients with CrCl<50 ml/min.
We should also be careful when co-administering colchicine with the following drugs: macrolides (i.e. clarithromycin), statins (i.e. pravastatin), ketoconazole and cyclosporin. There have been case reports of significant toxicity when colchicine is given together with these drugs in patients with renal disease.
Reference: El-Zawawy H, Mandell B. Managing gout: How is it different in patients with chronic kidney disease. Cleveland Clinic J Med 2019; 77 (12): 919-28.