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Antigout agent

(Updated Feb. 4, 2021)



  1. No dose adjustments are required based on age alone. Once corrected for renal function, the pharmacokinetics of colchicine do not differ significantly in older versus younger adults.
  2. Drugs which inhibit CYP3A4 (e.g. azole antifungals, HIV protease inhibitors, clarithromycin and erythromycin) and/or P-glycoprotein (e.g. amiodarone, cyclosporine, macrolides) increase colchicine levels. Concurrent use requires dose adjustment of colchicine.
  3. For any indication, colchicine is contraindicated in patients with renal or hepatic impairment and concurrent use with P-glycoprotein or potent CYP3A4 inhibitors.
  4. For the indication of gout prophylaxis, colchicine is contraindicated in patients with concomitant renal and hepatic impairment.
  5. No dose adjustments are required for patients with mild to moderate renal (>CrCl 30 mL/min) or hepatic (Child-Pugh class A or B) impairment


Benefits and Risks

Gout: The 2014 Cochrane review on colchicine for acute gout included two RCTs: A RCT (n=43; 22 intervention v. 21 control found that High-dose colchicine (oral 1 mg followed by 0.5 mg every 2 hours until toxicity or complete response occurred) resulted in acute gout-associated pain reduction by 50% absolute risk reduction of 34% (ARR 30% for decrease in clinical symptoms such as tenderness on palpaltion, swelling, redness, pain)compared to placebo with number needed to treat (NNT) of 3. However, all 22 patients in the intervention arm developed adverse events of nausea, vomiting, or diarrhea, with number needed to harm (NNH) of 1. An RCT (n=185; 52 high-dose v. 74 low-dose intervention v. 59 control) found that Both high-dose (1.2 mg followed by 0.6 mg every hour for 6 hours, total 4.8 mg in 6 hours) and low-dose colchicine (1.2 mg followed by 0.6 mg in 1 hour then placebo every hour for 5 hours, total 1.8 mg in 6 hours) resulted in significant response in the primary outcome (pain reduction by 50% at 24 hours) compared to placebo (2 placebo capsules followed by 1 capsule every hour for 6 hours) with NNT of 5. There was no difference in benefit between the high- and low-dose arms. However, high-dose colchicine had NNH of 2 for adverse events (nausea, vomiting, diarrhea), while low-dose colchicine had no additional harms compared to placebo (25.7% and 20.7%, RR 1.24, 95% CI 0.55 to 2.79).
Note: Generalizability is a concern, with the second RCT’s study population being mean age 51.5 ± 11.1 years, 95.1% male, 83% white, and no discussion of comorbidities. The Cochrane review notes no trials have examined the effect of colchicine “in populations with comorbidities or in comparison with other commonly used treatments, such as NSAIDs and glucocorticoids.”


Mechanism of Action: “(K)nown to decrease the inflammatory response to urate crystal deposition by inhibiting migration of leukocytes, to interfere with urate deposition by decreasing lactic acid production by leukocytes, to interfere with kinin formation, and to diminish phagocytosis and the subsequent anti-inflammatory response.”¹ It has a prophylactic, suppressive effect that helps reduce incidence of acute attacks, but it is neither analgesic nor uricosuric nor does it prevent progression to chronic gouty arthritis.¹


Dose in Older Adults: No dose adjustments are required based on age alone. Renal function should be calculated using the Cockcroft-Gault formula for creatinine clearance (CrCl).



Gout, Treatment of acute flare

Gout, Prophylaxis

Familial Mediterranean Fever (FMF)

Usual dose  1.2 mg at first sign of flare then 0.6 mg one hour later. Maximum recommended dose is 1.8 mg over one-hour period. Wait 12 hours to resume prophylactic dose. Some experts recommend continuing with 0.6 mg for 2-3 days post acute treatment. Wait at least three days to repeat high dose treatment. Recommended dosage is 0.6 mg once or twice daily or 1.2 mg once daily. Maximum recommended dose should not exceed 1.2 mg per day.                              Recommended dosage is 1.2-2.4 mg daily. The dosage should be increased as needed and as tolerated in increments of 0.3 mg/day, to maximum recommended dose of 2.4 mg per day. If intolerable side effects develop, dose should be decreased in increments of 0.3 mg/day. The total daily dose may be administered in one to two divided doses.
 Concurrent moderate CYP3A4 inhibitorA or given within 14 days Recommended adjusted dosage is 1.2 mg x 1 with dose repeated no sooner than three days later. Recommended adjusted dosage is 0.3 mg twice daily (if original dose was 0.6 mg twice daily) or 0.3 mg once daily (if original dose was 0.6 mg once daily).  Adjusted maximum daily dose is 1.2 mg. The total daily dose may be administered in one to two divided doses.
Concurrent potent CYP3A4 inhibitorB or given within 14 days Recommended adjusted dosage is 0.6 mg x 1 then 0.3 mg one hour later. Wait at least three days to repeat treatment. Recommended adjusted dosage is 0.3 mg once daily (if original dose was 0.6 mg twice daily) or 0.3 mg once every other day (if original dose was 0.6 mg once daily). Adjusted maximum daily dose is 0.6 mg. The total daily dose may be administered in one to two divided doses.
Concurrent P-glycoprotein inhibitorC

 Recommended adjusted dosage is 0.6 mg x 1 dose with dose repeated no sooner than three days later.

 Recommended adjusted dosage is 0.3 mg once daily (if original dose was 0.6 mg twice daily) or 0.3 mg once every other day (if original dose was 0.6 mg once daily).  Adjusted maximum daily dose is 0.6 mg. The total daily dose may be administered in one to two divided doses.
CrCl 30-80 mL/min

 No dosage adjustment required but monitor closely for adverse effects.

 No dosage adjustment required but monitor closely for adverse effects.

 No dosage adjustment required but monitor closely for adverse effects.

 CrCl <30 mL/min

 No dosage adjustment required but monitor closely for adverse effects, and treatment should not be repeated more frequently than every 14 days.

Recommended adjusted dosage is 0.3 mg once daily.

Recommended adjusted dosage is 0.3 mg once daily.


Recommended adjusted dosage is 0.6 mg x 1, and treatment should not be repeated more frequently than every 14 days.

Recommended adjusted dosage is 0.3 mg twice weekly.


 Recommended adjusted dosage is 0.3 mg x 1.

 Mild to moderate hepatic impairment

No dosage adjustment required but monitor closely for adverse effects.

No dosage adjustment required but monitor closely for adverse effects.

No dosage adjustment required but monitor closely for adverse effects.


Severe hepatic impairment

Dosage adjustment should be considered though not specifically provided, and treatment should not be repeated more frequently than every 14 days.

Dosage adjustment should be considered though not specifically provided.

Dosage adjustment should be considered though not specifically provided.



moderate CYP3A4 inhibitors:¹, Amprenavir, Aprepitant, Diltiazem, Erythromycin, Fluconazole, Fosamprenavir (pro-drug of Amprenavir), Grapefruit juice, Verapamil, Voriconazole

potent CYP3A4 inhibitors:¹, Atazanavir, Clarithromycin, Darunavir/Ritonavir, Idelalisib, Indinavir, Itraconazole, Ketoconazole, Lopinavir/Ritonavir, Nefazodone, Nelfinavir, Ribociclib, Ritonavir, Saquinavir, Telithromycin, Tipranavir/Ritonavir

P-glycoprotein inhibitors:¹,² Amiodarone, Azithromycin, Clarithromycin, Cyclosporine, Digoxin, Diltiazem, Erdafitinib, Erythromycin, Felodipine, Ketoconazole, Lansoprazole, Lasmiditan, Lumacaftor and Ivacaftor, Nifedipine, Omeprazole, Paroxetine, Ranolazine, Sertraline, Quinidine, Tamoxifen, Verapamil


  • For the treatment of gout acute flares, use of colchicine is not recommended in patients with renal or hepatic impairment receiving prophylactic colchicine.
  • For any indication, concurrent use of colchicine and P-gp or strong CYP3A4 inhibitors in patients with renal or hepatic impairment is contraindicated.
  • See Appendix for off-label indications.
  • Colchicine can result in false-positive urine tests for erythrocytes¹¹

Dosage form: In Canada, only available as 0.6 mg tablets.

Adverse Effects

Common:¹,² Gastrointestinal – gastrointestinal disease (26% to 77%), diarrhea (23% to 77%), vomiting (17%), nausea (4% to 17%)

Less Common:¹,² Central nervous system – fatigue (1% to 4%), headache (1% to 2%);
Endocrine & metabolic – gout (4%);
Gastrointestinal – abdominal cramps, abdominal pain;
Respiratory – pharyngolaryngeal pain (2% to 3%)

Rare:¹,² Hematological – hypersensitivity reaction, leukopenia, granulocytopenia, thrombocytopenia, pancytopenia, aplastic anemia, bone marrow depression, disseminated intravascular coagulation;
Hepatobiliary – elevated AST, elevated ALT, hepatotoxicity;
Musculoskeletal – myopathy, elevated CPK, myotonia, muscle weakness, muscle pain, rhabdomyolysis;
Neurological – sensory motor neuropathy, peripheral neuritis, toxic neuromuscular disease;
Dermatological – alopecia, dermatitis, maculopapular rash, purpura, rash;
Digestive – dysgeusia, lactose intolerance


  • Prolonged administration could cause blood dyscrasias.
  • Colchicine is a toxic substance and must be given only under physician’s care. Since administration is subject to wide variations, the prescribed dosage must be strictly followed.
  • Use with care in geriatrics or debilitated patients and those with cardiac, renal, or gastrointestinal disease. Dosage reduction may be necessary in these cases and is indicated if weakness, anorexia, nausea, vomiting, or diarrhea appears. 


  • Patients with serious (not explicitly defined in product monograph) gastrointestinal, hepatic, renal, and cardiac disease.
  • Patients with known hypersensitivity to colchicine.
  • Patients with renal or hepatic impairment should not be given colchicine in conjunction with P-glycoprotein or strong CYP3A4 inhibitors. This can be fatal.

Monitoring Parameters²

  • CBC, renal profile, liver profile. Frequency not specified in product monograph, but suggest one week after initiation of colchicine and one week after any dose change of colchicine, change in renal or hepatic function, or initiation of a CYP3A4 or P-gp inhibitor.
  • B12 level. Suggest checking six months after initiation of colchicine.

Discontinuation/withdrawal considerations: None.


“Disrupts cytoskeletal functions by inhibiting -tubulin polymerization into microtubules, preventing activation, degranulation, and migration of neutrophils associated with mediating some gout symptoms. In familial Mediterranean fever, may interfere with intracellular assembly of the inflammasome complex present in neutrophils and monocytes that mediate activation of interleukin-1.”


Pharmacokinetic considerations in older adults: Although some references²,³state the mean peak plasma levels and AUC were higher in older adults versus healthy young adults, review of the source pharmacokinetic study shows renal function is likely the determining factor.

Absorption: Bioavailability ~45%, time to peak in serum 0.5-3 hours
Distribution:³ Protein binding ~39%. Substrate of P-glycoprotein/ABCB1. Highest concentrations in leukocytes, kidney, spleen, and liver; does not distribute in heart, skeletal muscle, or brain. Volume of distribution 5-8 L/kg. Plasma half life of a single 1mg dose is 4.4 hours. Half life in leukocytes is ~60 hrs.¹¹
Metabolism:³ Hepatic via CYP3A4 (major) is responsible for 16%, while glucuronidation also occurs. Three metabolites, with two primary (2-O-demethylcolchicine and 3-O-demethylcolchicine) and one minor (10-O-demethylcolchicine, a.k.a. “colchiceine”). Plasma levels of primary metabolites are <5% of parent drug. Activity of metabolites is unknown.
Elimination half-life:³ 27-31 hours in young, healthy volunteers receiving multiple oral doses.
Excretion:³ Urine (10-20% as unchanged drug). Enterohepatic recirculation, biliary excretion, and P-glycoprotein efflux also possible. Most of the drug is reported to be excreted in the feces, though percentages not available.
Pharmacokinetics in renal impairment:³ Patients with ESRD had 75% lower clearance and prolonged elimination half-life.
Pharmacokinetics in liver disease:³ Clearance is significantly reduced and plasma half-life prolonged in patients with mild to moderate cirrhosis.

Clinically Significant Drug Interactions

  • Colchicine has been shown to induce reversible malabsorption of Vitamin B12, apparently by altering the function of ileal mucosa.¹
  • Although colchicine exposure was not affected when coadministered with voriconazole (strong) or cimetidine (mild CYP3A4 inhibitor), fluconazole (moderate CYP3A4 inhibitor) 200 mg/day for 4 days plus a 400-mg loading dose increased the AUC of colchicine by 40%.
  • Other published reports have shown colchicine toxicity when coadministered with clarithromycin, erythromycin, and grapefruit juice, all moderate to strong CYP3A4 inhibitors.
  • Drug interactions with CYP3A4 inhibitors that are not also P-glycoprotein inhibitors cannot be ruled out, but combination inhibitors are more likely to lead to clinically meaningful interactions.
  • Case reports have been received for increased colchicine toxicity when coadministered with P-glycoprotein inhibitors such as cyclosporine; thus, such interactions cannot be ruled out.
  • Colchicine-induced neuromuscular toxicity and rhabdomyolysis have been reported with chronic treatment in therapeutic doses. Patients with renal dysfunction and elderly patients, even those with normal renal and hepatic function, are at increased risk. Concomitant use of atorvastatin, simvastatin, pravastatin, fluvastatin, gemfibrozil, fenofibrate, fenofibric acid, or benzafibrate (themselves associated with myotoxicity) or cyclosporine with colchicine may potentiate the development of myopathy. Once colchicine is stopped, the symptoms generally resolve within 1 week to several months.
  • Digitalis glycosides are substrates of P-glycoprotein and may increase concentration of colchicine. Cases of rhabdomyolysis have been reported in patients combining Digoxin and colchicine with FMF.¹¹

Increased plasma concentrations of colchicine have been observed when combined with Azithromycin. Monitoring for signs of toxicity is recommended when using together. ¹¹


  • None.

Pharmacogenomics¹ No prescribing info, clinical annotations, or pathways available.


  1. Odan Laboratories Ltd. Colchicine product monograph. Revised 4 May 2016. Accessed from Health Canada Drug Product Database on 30 January 2020.
  2. Lexicomp. Colchicine. Updated 30 Jan 2020. Accessed via University of Toronto Libraries.
  3. Micromedex. Colchicine. Updated 1 Jan 2020. Accessed via
  4. Takeda Pharmaceuticals America, Inc. Colchicine product monograph. Revised Nov 2012. Accessed from U.S. Food and Drug Administration FDA-Approved Drugs database on 30 January 2020.
  5. van Echteld I, Wechalekar MD, Schlesinger N, Buchbinder R, Aletaha D. Colchicine for acute gout. Cochrane Database Syst Rev. 2014 Aug 15;(8):CD006190. doi: 10.1002/14651858.CD006190.pub2.
  6. Ahern MJ, Reid C, Gordon TP, McCredie M, Brooks PM, Jones M. Does colchicine work? The results of the first controlled study in acute gout. Aust NZ J Med 1987;17:301-4.
  7. Terkeltaub RA, Furst DE, Bennett K, Kook KA, Crockett RS, Davis MW. High versus low dosing of oral colchicine for early acute gout flare: Twenty-four-hour outcome of the first multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-comparison colchicine study. Arthritis Rheum 2010;62:1060-8.
  8. Flockhart Table. Cytochrome P450 drug interactions table. Accessed from Indiana University on 1 February 2020.
  9. Rochdi M, Sabouraud A, Girre C, Venet R, Scherrmann JM. Pharmacokinetics and absolute bioavailability of colchicine after i.v. and oral administration in healthy human volunteers and elderly subjects. Eur J Clin PharmacoI. 1994;46:351-4.
  10. PHARMGKB. Colchicine. Accessed via
  11. Colchicine CPhA Product Monograph. (2019, September). Retrieved April 16, 2020, from
  12. MicroMedex. Colchicine US Product Monograph.
  13. Unproven Therapies for COVID-19: BC Centre for Disease Control/BC Ministry of Health. (2020, April 12). Retrieved April 16, 2020, from
  14. Gandolfini, I., Delsante, M., & Fiaccadori, E. (n.d.). COVID19 in kidney transplant recipients. American Journal of Transplantation. Retrieved from
  15. Kwon, O. C., Hong, S., Ghang, B., Kim, Y.-G., Lee, C.-K., & Yoo, B. (2017). Risk of Colchicine-Associated Myopathy in Gout: Influence of Concomitant Use of Statin. The American Journal of Medicine, 130(5), 583–587. doi: 10.1016/j.amjmed.2016.12.006 

I.      Administration¹

  • Administer orally with water and maintain adequate fluid intake.
  • Avoid grapefruit juice. May be administered without regard to meals.
  • May need to supplement with Vitamin B12.

 II.    Off-label indications

  1. Calcium pyrophosphate crystal arthritis (“pseudogout”), Acute flares of:²
    • Limited data, but expert opinion states same approach as for patients with gout.
  2. Calcium pyrophosphate crystal arthritis (“pseudogout”), Prophylaxis of:²
    • Limited data, but expert opinion states same approach as for patients with gout.
  3. Pericarditis, Treatment of acute or recurrent episodes of:²
    • Patients 70 kg: 0.6 mg twice daily
    • Patients <70 kg or unable to tolerate higher dosing regimen: 0.6 mg once daily
  4. Behçet syndrome:²
    • 1.2 to 1.8 mg/day in 2 to 3 divided doses
  5. Vasculitis, cutaneous small-vessel (idiopathic):²
    • Usual dose studied is 0.6 mg twice daily; if no response after 1 to 2 weeks, may consider increasing to 0.6 mg 3 times daily.


Recommendation: Recommend against the use of colchicine for treatment or prophylaxis outside a randomized-controlled trial.

Human Data:

There are several ongoing clinical trials, based on the potential anti-inflammatory effects of colchicine.¹³

  1. The Montreal Heart Institute COLCORONA Study is a phase 3 multi-centre, randomized, double-blind, placebo-controlled outpatient study (n=6000) to determine the efficacy and safety of   colchicine 0.5 mg PO bid x 3 days, then 0.5 mg daily x 27 days vs. placebo for treatment of COVID-19 infection in reducing death and lung complications. Media release Jan 23, 2021, Manuscript submission Jan 26, 2021 for peer-review. Draft manuscript available Jan 27 2021.

    Hypothesis: SARS-CoV1 (aka SARS), similar to SARS-COV2, activates NLRP3 inflammasome-mediated inflammatory cascade. SARS-CoV2 is tubulin polymerization may affect inflammasome, cellular adhesion molecules and inflammatory associated with high IL-6 levels resulting in cytokine storm. Therefore colchicine’s inhibition of chemokines which may improve outcomes among SARS-COV2 non-hospitalized patients.

    P-multicentre (Montreal Quebec Canada, New York San Franciso USA, Madrid Spain, Sao Paulo Brazil)  
    age >40 years (adults), dx SARS-CoV2 within preceding 24 hours (PCR from nasopharyngeal swab OR household member with a POSITIVE nasopharyngeal swab with COVID19 symptoms, OR clinical algorithm in symptomatic patient without obvious alternative cause), outpatients (not hospitalized nor considering hospitalization),
    PLUS one of:
    age >=70 years,
    obesity (BMI >=30),
    uncontrolled HTN (SBP >=150 mmHg),
    known respiratory disease,
    known heart failure,
    known CAD,
    fever >38.4C within the last 48 hrs,
    dyspnea at the time of presentation,
    bicytopenia, pancytopenia or neutrophilia AND lymphopenia

    Exclusions: women of childbearing age NOT practicing adequate contraception, IBD, chronic diarrhea or malabsorption, concomitant progressive neuromuscular disease, GFR<30cc/min/1.73 m2, severe liver disease, current tx with colchicine, chemo for cancer, sensitivity to colchicine.
    I-colchicine 0.5 mg BID for 3 days and then daily for 27 days. Delivered to patient’s house within 4 hours.
    C-placebo (1:1)
    O-COMPOSITE of death or hospital admission for COVID19 within 30 days of randomization. Secondary endpoints is each of death /hospitalization/mechanical ventilation in 30 d. tertiary outpoints pneumonia, serious adverse events, nonserious adverse events.
    S-randomized, double-blind placebo controlled investigator initiated trial; Mar-Dec 2020. ; Stopped prematurely after 75% recruitment of sample size due to pressures of running 24 hr call centre and pandemic
    Telephone clinical evaluations at 15 and 30 days.
    confirmation that patient took intervention
    N=4488 randomized and followed for 30 days. 97.9% completion.
    Enrollment mean 5.3 days after onset of COVID
    Patients age, sex, Caucasian (93%), BMI, smoking, HTN (35-37%), diabetes (20%), respiratory disease (26%), prior MI 3%, prior heart failure (0.8-1%) generally similar between groups
    Mean age 54.7 years
    53.9% women
    Mean BMI 30
    19.9% diabetes.
    Mean tx duration 26.2 days.
    Primary endpoint in 4.7% of patients in colchicine vs 5.8% placebo.  P 0.08. ARR 1.1%
    Among patients with PCR confirmed COVID, primary endpoint 4.6% colchicine and 6% placebo p= 0.04 ARR 1.4% NNT 72 patients.
    SAE 4.9% colchicine vs 6.3% placebo p=0.05 “NNT” 52 patients
    PE 0.5% colchicine vs 0.1% placebo p = 0.01
    Trial medication-related adverse events 24.2% colchicine vs 15.5% placebo, ARR 8.7% NNH  11.5; at least 1 treatment emergency GI adverse event in 23.9% colchicine group, as compared with 14.8% placebo

    Prespec subgroup analysis: age>=70 years. 18/190 (9.5%) colchicine and 27/213 (12.7%) OR 0.72 (0.38 to 1.36)
  2. Deftereos 2020 GRECCO-19 Study is conducting a prospective, randomized, open labelled, controlled study (n=180) in Greece comparing usual medical treatment and colchicine 1.5 mg PO x 1 (1 mg PO x 1 if receiving azithromycin), followed 60 min by 0.5 mg if no gastrointestinal effects), then 0.5 mg PO BID for weight >60 kg [0.5 mg PO daily if <60 kg] vs. usual medical treatment. The endpoints are time for CRP levels to be >3xUNL, difference in troponin within 10 days, and time to clinical deterioration.
  3. An Italian phase 2 randomized, open-label study(n=100) evaluating colchicine 1 mg (or 0.5 mg in chronic kidney disease)/day and standard of care vs. only standard of care in mild and moderately ill COVID-19 positive patients with the endpoints of time to clinical improvement or hospital discharge.
  4. This is an Argentinian phase 3 randomized, open-label, controlled trial (n=2500) assessing colchicine arm [colchicine 1.5 mg, then 0.4 mg after 2 hours, followed by 0.5 mg PO BID x 14 days or until discharge; if patient is receiving lopinavir/ritonavir, colchicine 0.5 mg, then after 72 hours 0.5 mg PO q72 hours x 14 days or until discharge; if patient is starting on lopinavir/ritonavir, colchicine 0.5 mg 72 hours after starting Kaletra, then 0.5 mg PO q72 hours x 14 days or until discharge] vs. standard of care in moderate/high-risk COVID-19 patients. The primary endpoint is all-cause mortality.
  5.  Case report on an Italian kidney transplant patient in respiratory failure admitted to ICU who was treated with colchicine, due to unavailability of Tocilizuzmab, with 1mg on day 8 and 0.5 mg daily thereafter.14  He also received antiretrovirals and hydroxychloroquine. 24 hours after colchicine administration plasma IL-6 concentration decreased significantly (from 108 to 36) and respiratory conditions stabilized. In the presented kidney transplant recipients, the course of COVID19 did not significantly differ from that of non transplant individuals. Immunosuppression interruption combined to the anti inflammatory effects of colchicine may have synergized with antiviral therapy and hydroxychloroquine to lower viral replication and minimize the cytokine storm triggered by SARS CoV2.
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