Colchicine: A Fresh Look at an Old (But Not Stale) Drug

Colchicine has been around a long time and has been a mainstay in the treatment and prevention of gout. It binds to tubulin dimers and inhibits vesicle transport, cytokine secretion, phagocytosis, and specifically in neutrophils, inhibits chemotaxis and enzyme release during phagocytosis.¹ Let’s look at tried-and-true uses for the drug, but add some new ones as well.

Gout and Pseudogout

 Yes, colchicine is effective in gout, but did you know that the low-dose regimen of 1.2 mg followed by 0.6 mg 1 hour later is just as efficacious as the traditional (old) high dose of 1.2 mg followed by 0.6 mg every hour for a maximum of 4.8 mg?¹ The lower dose also goes a long way in decreasing serious side effects. 

Note: Colchicine is just as effective in the treatment of pseudogout.

Prophylaxis Against Acute Gouty Arthritis

Prophylaxis is especially important when instituting urate-lowering therapy (allopurinol or febuxostat). This fact has been known for years, but what is new is the duration of colchicine prophylaxis should be 6 months and not 8 weeks as previously considered.¹ Prophylactic regimens is 0.6 mg dosed once or twice daily.

Pseudogout

Colchicine for acute attacks should be dosed 0.5 mg 3 times per day and 0.5 mg daily for prophylaxis.¹

Pericarditis

Patients with recurrent pericarditis achieved more improvement at 72 hours with colchicine therapy (compared to aspirin or prednisone with or without colchicine) and after 18 months, experienced a 51% reduction in the rate of recurrent pericarditis as compared to 24% in the group without colchicine.¹ Colchicine’s efficacy was determined by the CORE trial,² which followed 84 subjects randomized with recurrent pericarditis aspirin or prednisone versus colchicine. The results showed that colchicine was clearly superior to either aspirin or prednisone.

Coronary Artery Disease

There is preliminary evidence that colchicine may decrease C-reactive protein levels, myocardial infarctions, and mortality in people with coronary disease.¹ Furthermore, there is evidence that colchicine may prevent stent stenosis in patients with diabetes and coronary disease.¹ A recently added new indication recommends the preoperative administration of colchicine for open heart surgery; data shows a 45% reduction in postoperative atrial fibrillation with this use.³

Vasculitis

The Top Paper¹ also reviewed evidence for colchicines in familial Mediterranean fever and vasculitis. Colchicine use in the treatment of mucocutaneous lesions and joint symptoms of Behçet’s disease decreased disease activity significantly.

The authors note that “colchicine is one of the oldest therapeutic substances known to mankind, yet the scope of its benefits has only recently been the subject of active study.”¹ The recent inroads into new clinical applications for colchicine—each characterized by complications consequent to inflammation (eg, pericarditis, atrial fibrillation, and coronary disease)—make this old drug a more common choice in a myriad settings. 

Gregory W. Rutecki, MD, is a physician at the National Consult Service at the Cleveland Clinic. He is also a member of the editorial board of Consultant. Dr Rutecki reports that he has no relevant financial relationships to disclose.

References:

1.Slobodnick A, Shah B, Pillinger MH, Krasnokutsky S. Colchicine: old and new. Am J Med. 2015;128(5):461-470.

2.Imazio M, Bobbio M, Cecchi E, et al. Colchicine as first-choice therapy for recurrent pericarditis: results of the CORE (Colchicine for Recurrent pericarditis trial). Arch Intern Med. 2005;165(17):1987-1991.

3.Imazio M, Brucato A, Ferrazzi P, et al. Colchicine reduces post-operative atrial fibrillation: results of the Colchicine for the Prevention of Postpericardiotomy Syndrome (COPPS) atrial fibrillation substudy. Circulation. 2011;124(21):2290-2295.