#57 Is colchicine an effective alternative to NSAIDs for the treatment of acute gout?
CLINICAL QUESTION
For patients with acute gout, is colchicine an effective treatment, and when would its use be indicated?
BOTTOM LINE
Colchicine is a reasonable option for the treatment of acute gout, especially in patients in whom NSAIDs are contraindicated. Optimal dosing that balances treatment benefit with potential adverse events remains to be determined, but low dose is recommended.
Reading Tools for Practice Article can earn you MainPro+ Credits
Join NowAlready a CFPCLearn Member? Log in
EVIDENCE
Two Randomized Controlled Trials (RCTs)1,2 provide the best-available evidence to answer this question:
- Industry-funded trial1 with unclear risk of bias:
- Population: 575 patients with gout randomized in a blinded fashion to low- or high-dose colchicine or placebo for the next gout attack (185 patients had a gout attack requiring study drug).
- Interventions:
- Low-dose: 1.2 mg, then 0.6 mg one hour later (1.8 mg total).
- High-dose: 1.2 mg, then 0.6 mg every one hour x 6 hours (4.8 mg total).
- Primary outcome: Achieved ≥50% reduction in pain at 24 hours without use of ‘rescue’ medicine.
- Statistically significant benefit with low-dose colchicine versus placebo (37.8% vs. 15.5%, Number Needed to Treat (NNT)=5).
- No difference between low- and high-dose colchicine (37.8% versus 32.7%).
- Adverse events:
- Low-dose colchicine had statistically significantly fewer adverse events than high-dose.
- Diarrhea: 26% versus 77%, NNT=2.
- Nausea: 4% versus 17%, NNT=8.
- Low-dose colchicine had statistically significantly fewer adverse events than high-dose.
- The only other placebo-controlled trial2 of colchicine for acute gout showed a similar benefit (NNT=3), however:
- High-dose regimen (1 mg, followed by 0.5 mg every two hours until complete pain relief or adverse events) resulted in 100% adverse event rate (vomiting or diarrhea).
- Systematic reviews found no other RCTs of colchicine.3,4
- The latest guidelines5,6 recommend low-dose colchicine, NSAIDs, or oral corticosteroids for acute gout.
- No published studies have directly compared colchicine to NSAIDs or corticosteroids,3,4 and no specific NSAID appears superior to another NSAID in treating acute gout.7
- Caution is recommended when using:
- NSAIDs in patients with hypertension, cardiovascular or renal impairment, or those at risk of gastrointestinal events.8
- Colchicine in patients with renal or hepatic impairment and patients on CYP3A4 inhibitors (clarithromycin, calcium-channel blockers, oral antifungals, and many more) or P-glycoprotein inhibitors (e.g. cyclosporine).8,9
Latest Tools for Practice
#379 Bumpin’ Up the Protection? RSV Vaccine in Pregnancy
How effective and safe is the respiratory syncytial virus (RSV) vaccine (AbrysvoTM) when given during pregnancy?
#378 Tony Romo-sozumab: Winning touchdown in osteoporosis or interception for the loss?
What is the efficacy and safety of romosozumab in postmenopausal women with osteoporosis?
#377 How to slow the flow IV: Combined oral contraceptives
In premenopausal heavy menstrual bleeding due to benign etiology, do combined oral contraceptives (COC) improve patient outcomes?
