Colchicine

1. Introduction

Colchicine is an anti-inflammatory medication primarily used to treat and prevent gout flares and manage familial Mediterranean fever (FMF). It works by inhibiting microtubule polymerisation, reducing the migration of inflammatory cells to affected areas. Colchicine does not affect uric acid levels but is highly effective in reducing inflammation associated with gout.

2. Indications

  • Approved Indications:
    • Treatment of acute gout flares.
    • Prevention of recurrent gout attacks.
    • Familial Mediterranean fever (FMF).
  • Off-Label Uses:
    • Pericarditis (recurrent or acute).
    • Behçet’s disease.
    • Coronary artery disease (inflammatory modulation).

3. Dosage

  • Acute Gout Flares:
    • Adults: 1.2 mg initially, followed by 0.6 mg 1 hour later. Maximum: 1.8 mg per episode.
    • Wait at least 3 days before repeating the dose for another flare.
  • Gout Prophylaxis:
    • Adults: 0.6 mg once or twice daily. Maximum: 1.2 mg/day.
  • Familial Mediterranean Fever (FMF):
    • Adults and Children ≥12 years: 1.2–2.4 mg/day in divided doses.
    • Children 4–12 years: 0.3–1.8 mg/day in divided doses, adjusted by weight.

4. Administration

  • Take orally with or without food.
  • To minimise gastrointestinal side effects, take with a full glass of water or a small meal.

5. Forms Available

  • Tablets: 0.5 mg, 0.6 mg.

6. Side Effects

6.1. Common Side Effects

  • Diarrhoea.
  • Nausea.
  • Abdominal pain.

6.2. Less Common Side Effects

  • Vomiting.
  • Fatigue.

6.3. Rare but Serious Side Effects

  • Bone marrow suppression (e.g., leucopenia, thrombocytopenia).
  • Myopathy and rhabdomyolysis (especially with renal impairment or interacting drugs).
  • Severe gastrointestinal bleeding.

7. Warnings

  • Toxicity can occur even at therapeutic doses; monitor closely, especially in patients with renal or hepatic impairment.
  • Avoid in patients with severe renal or liver impairment if they are taking strong CYP3A4 inhibitors or P-glycoprotein inhibitors.
  • Use cautiously in elderly patients due to increased risk of toxicity.

8. Precautions

  • Avoid grapefruit or grapefruit juice, which may increase colchicine levels and toxicity risk.
  • Monitor for muscle pain or weakness, particularly in patients on statins or other drugs that increase myopathy risk.
  • Discontinue treatment if severe diarrhoea or other significant gastrointestinal symptoms occur.

9. Interactions

  • Drug-Drug Interactions:
    • CYP3A4 inhibitors (e.g., clarithromycin, ketoconazole): Increased risk of colchicine toxicity.
    • P-glycoprotein inhibitors (e.g., cyclosporine): Elevated colchicine levels.
    • Statins: Increased risk of myopathy and rhabdomyolysis.
    • Digoxin: May increase colchicine toxicity.
  • Drug-Food Interactions:
    • Avoid grapefruit juice due to its effect on colchicine metabolism.

10. Monitoring Parameters

  • Monitor for signs of toxicity, such as severe diarrhoea, muscle pain, or blood dyscrasias.
  • Check complete blood count (CBC) in long-term use.
  • Monitor renal and liver function in at-risk patients.

11. Use in Children

  • Approved for familial Mediterranean fever (FMF) in children over 4 years.
  • Dosage should be carefully adjusted by weight.

12. Use in Pregnancy

  • Category C: Use only if potential benefits outweigh risks.
  • Limited evidence suggests colchicine may be safe in pregnancy for FMF under medical supervision.

13. Use in Elderly

  • Use with caution due to increased sensitivity and risk of toxicity. Start at the lowest effective dose and monitor closely.

14. Use in Kidney Disease

  • Dose adjustments are necessary for renal impairment:
    • Mild to moderate impairment: Use with caution.
    • Severe impairment: Avoid use in combination with strong CYP3A4 or P-gp inhibitors.

15. Use in Liver Disease

  • Dose adjustments are required for hepatic impairment. Avoid in severe liver dysfunction or with strong CYP3A4/P-gp inhibitors.

16. Patient Counselling Points

  • Take colchicine exactly as prescribed; do not exceed the recommended dose, as toxicity can occur even at therapeutic levels.
  • Report symptoms of muscle pain, weakness, or severe diarrhoea to your doctor immediately.
  • Avoid grapefruit juice while on colchicine.
  • For acute gout flares, start treatment at the first sign of symptoms for the best effect.
  • Do not use colchicine more than once every 3 days for acute gout flares.

17. Table of Brand Names, Manufacturers, and Prices

Brand NameManufacturerPrice (USD)
ColcrysTakeda$100–120 (30 tablets, 0.6 mg)
Generic OptionsVarious$10–30 (30 tablets, 0.6 mg)

18. FAQs (15 Questions)

  1. What is colchicine used for?
    Colchicine is used to treat and prevent gout flares and familial Mediterranean fever (FMF).
  2. How does colchicine work?
    It reduces inflammation by inhibiting white blood cell migration to inflamed areas.
  3. Can colchicine treat the pain of gout?
    Yes, it helps reduce the inflammation that causes pain during a gout flare.
  4. What are the common side effects of colchicine?
    Diarrhoea, nausea, and abdominal pain are common side effects.
  5. How should colchicine be taken for a gout flare?
    Take 1.2 mg at the first sign of a flare, followed by 0.6 mg 1 hour later.
  6. Can colchicine be used long-term?
    Yes, it is used long-term to prevent recurrent gout flares or manage FMF, but regular monitoring is required.
  7. Is colchicine safe for children?
    Yes, it is approved for FMF in children over 4 years, with dosage based on weight.
  8. Can colchicine be taken with other medications?
    Caution is needed, as colchicine interacts with drugs like CYP3A4 inhibitors, P-gp inhibitors, and statins.
  9. Can colchicine cause muscle pain?
    Yes, it may cause myopathy, especially when combined with statins or in patients with renal impairment.
  10. Can colchicine be taken during pregnancy?
    It may be used under medical supervision if the benefits outweigh the risks.
  11. What should I do if I miss a dose?
    Take it as soon as you remember, but skip it if it’s close to the next dose. Do not double the dose.
  12. Can colchicine cause serious side effects?
    Yes, severe diarrhoea, blood abnormalities, and muscle toxicity can occur, especially at higher doses.
  13. Is colchicine available over the counter?
    No, colchicine is a prescription-only medication.
  14. How should colchicine be stored?
    Store at room temperature, away from light and moisture.
  15. Can I drink alcohol while taking colchicine?
    It is advisable to limit alcohol, as it can worsen gout and increase the risk of side effects.