Colchicine in acute gout
BMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7426.1275 (Published 27 November 2003) Cite this as: BMJ 2003;327:1275All rapid responses
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Editor – we read with interest Morris et al’s Lesson of the Week on
the use of colchicine in gout (Morris I, Varughese G, Mattingly P.
Colchicine in acute gout. BMJ 2003; 327: 1275 -6). We agree that the
guidelines in the British National Formulary (BNF) do not reflect
established practice amongst Rheumatologists. Indeed, local guidelines
that have existed in our own large District General Rheumatology Unit for
at least five years advocate the use of colchicine 0.5mg twice or three
times daily both for acute gout, and also long term when allopurinol
therapy is insufficient. An editorial in The Lancet as long ago as 1989
similarly recommended colchicine as a safe and effective prophylactic
(Anon. Polyarticular gout. The Lancet 1989 April 1; 1(8640): 703-4.)
However, although the BNF mentions its use in prophylaxis, the emphasis is
on short-term usage; it is unfortunately our experience that prescriptions
for long-term therapy are commonly questioned by Pharmacies, as this
regime deviates from BNF guidance. Thus patients are denied effective
treatment.
Further, an ageing population with significant comorbidities means
that an appreciable proportion of patients presenting with difficult gout
are those with severe cardiac failure and / or renal insufficiency who are
treated with low-dose aspirin and diuretics. Thus non-steroidal anti-
inflammatory drugs are contraindicated. Low-dose colchicine is a useful
and safe member of the therapeutic armamentarium.
Competing interests:
None declared
Competing interests: No competing interests
I welcome Morris et al's discussion about the use of low dose
colchicine in gout.(1) The treatment dose of colchicine, which has
remained at 1 mg initially followed by 500 micrograms every 2-3 hours for
many years, should be reviewed. However, they are incorrect to state that
the current British National Formulary (BNF) recommends a regimen for
colchicine which is unchanged since the 1966 edition.
In September 1999, the BNF reduced the total dose of a course of
colchicine from 10mg to 6mg.(2) BNFs prior to 1981 did not even state the
higher limit of 10mg.
The decision to reduce the total dose of colchichine to 6mg was taken
because of expert advice given to the BNF. (3) They reported they found
little evidence to support the use of the total dose of 10mg and that a
total dose of 6mg has been recommended in the USA.(4)
After nearly 2000 years of recorded use of colchicine we are still
struggling to find its optimal dose. Recent history appears to be one of
a gradual reduction in the total dose. Morris et al's useful contribution,
suggesting a reduction in dose frequency, may reduce further the
unpleasant adverse effects of this useful agent.
1. Morris I, Varughese, Mattingly P. Colchicine in acute gout. BMJ
2003;327:1275-1276
2. Joint Formulary Committee. British National Formulary. Number 38
ed. London: British Medical Association and Royal Pharmaceutical Society
of Great Britain; 1999
3. British National Formulary FAQ.
http://www.bnf.org/AboutBNFFrameFAQ.htm (accessed on the 4th of December
2003)
4. Martindale: The Complete Drug Reference. 32nd edition, 1999.
Pharmaceutical Press. London.
Competing interests:
None declared
Competing interests: No competing interests
I was delighted to see Morris et al's lesson of the week. I have been
using colchicine in exactly this way for years to treat gout in the frail
elderly or those with multiple comorbidities. I have been scoffed at by
some fellow physicians for doing so (there being nothing else other than a
huge dose of non-steroidals that works apparently) but older and wiser
geriatricians than I have nodded their head in sage agreement at such an
approach.
Critics will no doubt demand a large multicentre randomised
controlled trial to expand upon the effect seen with the n=3 in this
report, but I was heartened to see the BMJ publish such a sensible article
based on "good old-fashioned clinical experience" using a "good old-
fashioned treatment".
The BNF should indeed take note of those who thumb it's pages most
regularly.
References: Morris I, Varughese G and Mattingly P. Lesson of the
week: Colchicine in acute gout. BMJ 2003;327:1275-1276.
Competing interests:
None declared
Competing interests: No competing interests
I have for many years only used Colchicine for patients with Gout who
were on ACEi's because of the interaction with NSAID's which could
precipitate Acute Renal Failure. The dose I use is 500mcg tds for a
maximum of 4 days. The gold standard treatment for Gout is indometacin 25-
50mg tds with or without a Gastro Protective Agent. Only 3-4 days is
usually needed.
Competing interests:
None declared
Competing interests: No competing interests
With reference to the article ‘Colchicine in acute gout’ the emphasis
by the authors is -“In acute gout, lower doses of colchicine are effective
yet less toxic than traditional regimens”1
However certain points need to be considered at this juncture.
a. In all the three cases quoted by the authors the patients were
initially started with higher (traditional) doses of colchicine and only
later (i.e. after the patients experienced adverse effects) were they
switched over to lower doses. This means a lingering effect of colchicine
would be present. There is evidence that colchicine will be present in
leucocytes (site of action) for at least 9 days following a single
intravenous dose2 . Hence to claim that a lower dose of colchicine is
effective, should not one start with a lower dose?
b. Because of the greater frequency of toxicity with colchicine,
NSAID [nonsteroidal anti-inflammatory drug (such as indomethacin or
naproxen)] is preferred2. Here again I would like to state that in one of
the three cases mentioned, meloxicam was tried without benefit. Meloxicam
is a drug with long half-life and it needs time for steady state
concentration to be achieved.
c. Colchicine has generally been replaced by less toxic drugs like
NSAIDs3, 4 or corticosteroids (preferably via intrasynovial injection)3
for relief of an acute attack. Colchicine should be reserved for patients
in whom these other agents are contraindicated or ineffective3. Though the
authors claim that they do not advocate an increase in the use of
colchicine it seems that all other avenues seem not exhausted
d. It has also been earlier reported that colchicine is equally
effective and the gastrointestinal side effects may be almost completely
avoided if given intravenously2.
1. Morris I, Varughese G, Mattingly P, Colchicine in acute gout, BMJ
2003; 327:1275–6
2. Roberts II LJ and Morrow JD In:Goodman & Gilman’s The
pharmacological basis of therapeutics. 10th Ed. New York: McGraw Hill;
2001. pp 687-731
3. Drug Evaluations Subscription. Chicago: American Medical
Association, Spring, 1990; 674-6.
4. Roberts WN, Liang MH, Stern SH. Colchicine in acute gout.
Reassessment of risks and benefits. JAMA 1987; 257: 1920-2.
I do hereby declare that there is no competing interest involved.
Competing interests:
None declared
Competing interests: No competing interests
Colchicine in acute gout? Try intramuscular steroids.
Dear Sir
Colchicine in acute gout. Try Intramuscular Steroids.
Lesson of the week 29th November 2003 draws attention to the high
rate of gastrointestinal side effects when colchicines is used to treat
acute gout.
The most recent British National Formulary still mentions “a
corticosteroid by intramuscularly injection” as an effective treatment. I
have used this successfully in musicians attending this clinic needing
urgent relief.
Yours sincerely
J A Mathews MA MD FRCP
Consultant Physician
Ref : British Medical Association, Royal Pharmaceutical Society of
Great Britain. British National Formulary. London: BMA, RPS 2003; 496.
(No. 46)
Competing interests:
None declared
Competing interests: No competing interests