Colchicine in acute gout: high-dose or low-dose or no-dose?
September 11, 2015, 6:37 pm
Does Colchicine Improve Pain in an Acute Gout Flare? Turner J, Cooper D. Ann Emerg Med 2015 sep;66:260-1.
The 7th edition of Tintinalli’s Emergency Medicine (2011) has this to say about using colchicine to treat gout:
Oral colchicine is typically administered in a dose of 0.6 milligrams/h until intolerable side effects (vomiting or diarrhea) or efficacy ensues.
This “typical” dosing schedule goes back decades, and even when I was a medical student who didn’t know an Ewald tube from an Ewok it never made sense to me. The instructions might as well have been “Take this until you’re better or you find you’re shitting and puking your guts out.”
And this dosing made even less sense when I realized that the “intolerable side effects” were actually symptoms of colchicine toxicity which can be — and not infrequently is — life-treatening.
Is there any evidence on this issue? This short synopsis summarizes a recent article updating the 2006 Cochrane review of the topic. The authors of that review found only 2 randomized controlled trials that met inclusion criteria. One trial (43 patients) gave 1 mg colchicine orally, then 0.5 mg every 2 hours until complete relief or toxicity, or placebo. The second study (575 patients) compared placebo v. high-dose colchicine (4.8 mg over 6 hours) v. low-dose colchicine (1.2 mg then 0.6 mg one hour later.)
The take-home message:
“Low-quality evidence suggests that both high- and low-dose colchicine decreases [sic] pain in acute gout flares; however, high-dose regimens are associated with more frequent adverse effects.”
Note that there were adverse effects associated with use of the low-dose regimen. (For that matter, there were also adverse effects in the placebo groups.) This synopsis gives no indication of the nature or severity of these effects. Unfortunately, there are no trials comparing colchicine to other modalities such as non-steriodal anti-inflammatory agents in these patients.
Also remember that renal insufficiency is a contraindication to the use of colchicine, especially in high doses.
To read my Emergency Medicine News column on colchicine toxicity, click here.