Know COLCHICINE's role in chronic coronary disease
Overview
As a cardiovascular pharmacist, you’ll hear buzz about new Rx colchicine (Lodoco) for patients with chronic coronary disease. There’s been growing interest in using colchicine to reduce CV risk, due to its anti-inflammatory effect...
NPS recommendations
Evidence supporting colchicine in CV risk reduction
"Lodoco" is the same drug we use for gout, but it’s 0.5 mg instead of 0.6 mg. And it’s the first colchicine approved to reduce CV risk.
- Evidence suggests that adding colchicine 0.5 mg/day to standard care (antiplatelets, statin, etc) for chronic coronary disease prevents 1 CV event for every 36 patients treated over about 2 years.
- Other data suggest that starting colchicine 0.5 mg/day within a few weeks after a heart attack also reduces CV events.
But be aware of limitations. For example, colchicine doesn’t reduce the risk of death, the CV benefit is driven by lower risk of angina, heart attack, and stroke. And data are scant with eGFR less than 60 mL/min/1.73 m².
Risks and toxicity considerations
On top of that, colchicine is tricky to use. There’s a narrow gap between effective doses and those that can cause severe or life-threatening toxicity, such as low blood counts and rhabdomyolysis. And risk of these toxicities goes up with higher colchicine levels, such as in patients with liver or kidney disease or with strong CYP3A4 or P-glycoprotein inhibitors (grapefruit, itraconazole, etc).
Colchicine in routine practice
Don’t jump to colchicine for chronic coronary disease. Lodoco tabs are expensive, and many payers don’t cover them or require prior authorization. And don’t routinely prescribe colchicine 0.6 mg instead. While it is less costly, there’s insufficient evidence to support its safe reduction of CV risk. Instead, focus on optimizing adherence to standard care, such as antiplatelets, BP management, and cholesterol-lowering meds.
- Save colchicine 0.5 mg/day for rare patients, such as those with recurrent CV events despite optimized CV meds if eGFR is above 60 mL/min/1.73 m² AND significant drug interactions can be avoided.
- If starting colchicine, explain that GI upset is common even with low doses.
- Educate to report muscle pain or weakness right away, many of these patients will also be on a statin, and the combo may increase myopathy risk. And emphasize to promptly report other signs or symptoms of toxicity, such as severe diarrhea or infection.
🔑 Colchicine 0.5 mg daily is FDA-approved for secondary prevention in patients w/ coronary artery disease.
— American College of Cardiology (@ACCinTouch) April 17, 2024
Read key points to remember from a state-of-the-art review on the long-term safety of low-dose colchicine for atherosclerosis: https://t.co/dklamPVGii #cvPrev
References
- Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023 Aug 29;148(9):e9-e119.
- Nidorf SM, Fiolet ATL, Mosterd A, et al. Colchicine in Patients with Chronic Coronary Disease. N Engl J Med. 2020;383(19):1838-1847.
- Tardif JC, Kouz S, Waters DD, et al. Efficacy and Safety of Low-Dose Colchicine after Myocardial Infarction. N Engl J Med. 2019;381(26):2497-2505.
- Nelson K, Fuster V, Ridker PM. Low-Dose Colchicine for Secondary Prevention of Coronary Artery Disease: JACC Review Topic of the Week. J Am Coll Cardiol. 2023;82(7):648-660.
- Hansten PD, Tan MS, Horn JR, et al. Colchicine Drug Interaction Errors and Misunderstandings: Recommendations for Improved Evidence-Based Management. Drug Saf. 2023;46(3):223-242.
