Should We Use Colchicine for Acute Gout, and If So, How Much?
July 30, 2010
Should We Use Colchicine for Acute Gout, and If So, How Much?
Abstract & Commentary
By Joseph E. Scherger, MD, MPH, Clinical Professor, University of California, San Diego. Dr. Scherger reports no financial relationship to this field of study.
Synopsis: A randomized controlled trial showed that low-dose colchicine, 1.2 mg initially followed by 0.6 mg at 1 hour, was equally effective with fewer side effects as high-dose colchicine, eight 0.6 mg pills over 6 hours. The < 40% response rate with 23% getting diarrhea in the low-dose group calls into question whether colchicine is the superior choice over NSAIDs for acute gout.
Source: Terkeltaub RA, et al. High versus low dosing of oral colchicine for early acute gout flare. Arthritis Rheum 2010;62:1060-1068.
Colchicine is a natural product from the plant, colchicum autumnale or meadow saffron. It is a toxic substance that has been used for medicinal purposes generically for 200 years. Its best known use has been for acute attacks of gout, but it also has been used as a cathartic and emetic, and for Familial Mediterranean Fever and pericarditis.1 Like other natural products not well studied for their uses, such as quinine, the FDA removed the generics from the market and gave exclusive rights to a major drug company to study and develop a brand name product. URL Pharma now has Colcrys in the same 0.6 mg pill, with a cost many times higher than the generics.
In a controlled multicenter trial based at the University of California San Diego and the San Diego VA Medical Center, 184 patients were randomized to receive low-dose colchicine (1.2 mg initially followed by 0.6 mg at 1 hour), high-dose colchicine (1.2 mg initially followed by 0.6 mg every hour for 6 hours), or placebo. The response was measured as ≥ 50% reduction in pain; 37.8% (28 of 74 patients) in the low-dose group responded, 32.7% (17 of 52 patients) in the high-dose group responded, and 15.5% (9 of 58 patients) in the placebo group responded. The most common side effect was diarrhea and 23% of the low-dose patients developed diarrhea compared with 76.9% of the high-dose patients. More than 17% (17.3%) of the high-dose patients had severe diarrhea compared with none in the low-dose group.
About one-third of the patients in both treatment groups took a "rescue" medication because of recurrence of symptoms, usually indomethacin. Half of the placebo group patients required the rescue medication. The authors conclude that low-dose colchicine gave comparable results in treating acute gout to high-dose therapy with many fewer side effects, especially diarrhea.
Commentary
Over my 35 years of medical practice, I have avoided colchicine and used high-dose NSAIDs to treat acute attacks of gout. While colchicine gave some diagnostic value, that seemed a large price to pay for the high side-effect profile. The NSAIDs ibuprofen and naproxen were released during my years of medical education in the 1970s and I welcomed them as a preferred treatment for acute gout.
Now that a major drug company has a new brand name colchicine product, we are likely to see more studies like this supported by the industry. Most NSAIDs are generic and much less expensive than Colcrys for treating acute gout. The side effect profile of colchicine is such that there are plaintiff attorneys specializing in colchicine cases, although most of these are from IV use. This study tries to convince us that only 3 pills are needed, but more than 20% of the patients still got diarrhea, and one-third of patients had to take an NSAID anyway as a rescue medication. Some patients cannot tolerate NSAIDs and the low-dose treatment with colchicine would be helpful in these cases. I suspect that I will use some number of pills between the low dose and high dose in this study for more severe cases of acute gout.
Reference
1. Colchicine. Wikipedia. Available at: http://en.wikipedia.org/wiki/Colchicine. Accessed July 4, 2010.
A randomized controlled trial showed that low-dose colchicine, 1.2 mg initially followed by 0.6 mg at 1 hour, was equally effective with fewer side effects as high-dose colchicine, eight 0.6 mg pills over 6 hours. The < 40% response rate with 23% getting diarrhea in the low-dose group calls into question whether colchicine is the superior choice over NSAIDs for acute gout.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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