Colchicine in acute gouty arthritis: the optimum dose?

We applaud Cronstein and Terkeltaub [1] on their comprehensive review of the inflammatory process of gout and its treatment. Although they allude to the fact that colchicine probably has the smallest therapeutic window of any drug used to treat acute gouty arthritis, they have suggested "In treating acute gouty arthritis colchicine is typically administered as an oral 0.6 mg dose, followed by 0.6 mg at hourly intervals until gastrointestinal side effects (e.g. nausea, vomiting, or diarrhea) occur or a maximum total of six to eight doses has been administered" (see also the recommended dosage in Table 1 in [1]).

This is very similar to the dosage of colchicine suggested a decade ago [2], and indeed comparable to the regimen that was also expressed in grains in Hollander's Textbook of Rheumatology in 1960 [3]. Despite the fact that there is perhaps only one double blind placebo controlled study on colchicine in acute gout where gastrointestinal side effects occurred before the relief of pain [1], and the optimal dose of colchicine still remains elusive, there has not been any significant change to the recommended dosage in acute gout nearly half a century later [1]. The suggestion to administer colchicine at frequent intervals until the development of gastrointestinal side effects is a matter of significant concern [4], from a practical perspective, in routine clinical practice.

Of late, a recent systematic review has shown that there is a lack of robust data to inform the debate on the management of a common problem such as gout and, interestingly, all of the drugs used to treat gout can have serious side effects [5]. Indeed, Morris and colleagues [6] had suggested an effective yet less toxic alternative regime with colchicine in the setting of acute gout, and such anecdotal published case reports should not be underestimated and dismissed too quickly, as they remain a valid and efficient source for signal generation and are of great value for drug safety.