Colchicine in acute gout

Editor—Cox rightly points out that a total dose of colchicine has been introduced to advice in the BNF (British National Formulary) in recent years and is now at a 6 mg limit. The advice that has not changed is the traditional high dose regimen of 1 mg, followed every two hours by 0.5 mg, until relief of pain is obtained or vomiting or diarrhoea occurs.¹

In Ahern et al's study all patients given high dose colchicine developed diarrhoea or nausea in 12-36 hours with a mean dose of 6.7 mg²; many patients taking high doses who have been referred to us have gastrointestinal adverse effects below a total dose of 6 mg. We find that the total dose is not really relevant for acute situations with the low dose regimen.

Sivagnanam wonders if our patients settled because of the residual effect of the previously administered high dose colchicine that we had stopped; we only reintroduced colchicine, however, if the gout was not settling or was worsening. We have treated other patients with acute gout by using low dose colchicine from the beginning, and symptoms in these patients settled promptly and without adverse event.

Whether non-steroidal anti-inflammatory drugs (NSAIDs) are less toxic than colchicine is debatable, particularly compared with low dose colchicine. Normally we use NSAIDs first unless there are contraindications or adverse events, as seen in our cases. Intrasynovial steroids are not always practicable.

We cannot recommend intravenous colchicine and agree with Pawlotsky that although highly effective it should no longer be used, because of local and general complications associated with a risk of death.³