Cochrane for Clinicians

Putting Evidence into Practice

Colchicine for Acute Gout

 


FREE PREVIEW. AAFP members and paid subscribers: Log in to get free access. All others: Purchase online access.


FREE PREVIEW. Purchase online access to read the full version of this article.

Am Fam Physician. 2015 Jun 1;91(11):759-760.

Author disclosure: No relevant financial affiliations.

Clinical Question

Should colchicine be used to treat acute gout?

Evidence-Based Answer

Low-quality evidence shows that low-dose colchicine (up to 1.8 mg over one hour) is an effective therapy for acute gout. However, it has not been compared with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids in clinical trials. Concerns include high cost, drug-drug interactions, and potential toxicity. (Strength of Recommendation: B, based on inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Colchicine is an alkaloid inhibitor of microtubule formation derived from the meadow saffron or autumn crocus in the Northern Hemisphere. It has been used since ancient times for medicinal purposes. In 2009, after sponsoring a small randomized controlled trial, URL Pharma received exclusive rights to produce colchicine (Colcrys) for gout and the much rarer disease, familial Mediterranean fever. As a result, the price increased 50-fold from about $0.10 to $5.00 per pill.1

This Cochrane review updates a 2006 meta-analysis of a single study of 43 people. A second industry-sponsored study of 185 people was added to the current review. Both were randomized controlled trials. In the more recent study, the authors compared a high-dose colchicine regimen to a low-dose regimen. The high-dose regimens in the two studies—which included a 1- to 1.2-mg loading dose, followed by either 0.6 mg every hour for six hours or 0.5 mg every two hours until therapeutic response or intolerance (i.e., nausea, vomiting, or diarrhea)—caused significantly more adverse effects (number needed to treat to harm = 2). The shorter, low-dose regimen of 1.2 mg, followed by 0.6 mg in one hour (followed by placebo every hour for five hours) was as effective as the higher dosages in the more recent study, but with adverse effects similar to those in the placebo group. Using an outcome of at least 50% pain reduction at 24 to 32 hours with low-dose colchicine vs. placebo, the number needed to treat for the low-dose regimen was five.

No trials compared colchicine with other interventions (e.g., NSAIDs, corticosteroids). Most participants in these two studies were men, and this Cochrane review does not address whether colchicine is beneficial after the first two days of an exacerbation.

The 2012 American College of Rheumatology guidelines for managing gout state that low-dose colchicine is equal to NSAIDs and corticosteroids for treating acute gout.2 For severe acute gout, colchicine may be used with NSAIDs or corticosteroids. The guidelines call for at least six months of anti-inflammatory prophylaxis while starting urate-lowering therapy to prevent gout flare-ups, and slightly favor colchicine in a dosage of 0.6 mg once to twice daily in this regard.

The dose of colchicine should be reduced for patients with severe renal or hepatic disease. There is a 1% risk of reversible axonal neuromyopathy in patients taking colchicine; colchicine can cause rhabdomyolysis when used with statins or clarithromycin (Biaxin); and colchicine has multiple drug-drug interactions with cytochrome P3A4 inhibitors, including certain antiviral agents, antifungal agents, calcium channel blockers, and grapefruit.3,4 Comparative studies among the different treatments for acute gout and for flare-up prophylaxis are needed.

Author disclosure: No relevant financial affiliations.


The practice recommendations in this activity are available at http://summaries.cochrane.org/CD006190.

SOURCE:

van Echteld I, et al. Colchicine for acute gout. Cochrane Database Syst Rev. 2014;(8):CD006190.

REFERENCES

show all references

1. Kesselheim AS, et al. Incentives for drug development—the curious case of colchicine. N Engl J Med. 2010;362(22):2045–2047....

2. Khanna D, et al. 2012 American College of Rheumatology guidelines for management of gout. Part 2: therapy and antiinflammatory prophylaxis of acute gouty arthritis. Arthritis Care Res (Hoboken). 2012;64(10):1447–1461.

3. Colcrys (colchicine) tablets for oral use. Highlights of prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022351lbl.pdf. Accessed April 13, 2015.

4. Hainer BL, et al. Diagnosis, treatment, and prevention of gout. Am Fam Physician. 2014;90(12):831–836.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at http://www.aafp.org/afp/cochrane.



 

Copyright © 2015 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions


More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2016

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article