Clinical question
Is colchicine effective for secondary prevention in cardiovascular (CV) disease?
Bottom line
Daily low-dose colchicine lowers the risk of CV events in people with coronary artery disease (CAD) by about 1% per year (a relative risk reduction [RRR] of about 30%) but raises the risk of gastrointestinal events by approximately 2% and has no effect on mortality.
Evidence
Differences were statistically significant unless noted.
● Three systematic reviews comparing the effects of colchicine versus placebo in addition to standard therapy in individuals with CAD (4 to 11 RCTs; 5820 to 12 869 participants; duration 5 days to 3 years) found1-3:
● The 2 largest, placebo-controlled, non–industry funded RCTs were the LoDoCo24 and COLCOT trials.5
- LoDoCo24 compared colchicine 0.5 mg daily versus placebo for 2.5 years in 5522 people with stable CAD.
— The CV event rate (CV mortality, myocardial infarction [MI], ischemic strokes, urgent revascularization) was lower with colchicine (6.8% vs 9.6%), with a RRR of 29% and number needed to treat (NNT) of 36.
— Mortality did not differ (2.6% vs 2.2%).
— The only difference in adverse events was a higher risk of myalgia in the colchicine group (with a number needed to harm of 38).
- COLCOT5 compared colchicine 0.5 mg daily versus placebo for 23 months in 4745 participants within 1 month after MI.
— The rate of CV events was lower with colchicine (5.5% vs 7.1%, RRR = 24%, NNT = 63).
— Mortality did not differ (1.8% in both groups).
— Rates of adverse events did not differ.
Context
Recent guidelines for secondary prevention in CAD or after MI make no recommendations about colchicine.6
A 3-month supply of the new 0.5-mg dose costs approximately $45 (vs $25 for the 0.6-mg dose).7,8
Colchicine lowered the risk of CV events better than (eg, ezetimibe, RRR about 6%) or comparably to (eg, acetylsalicylic acid or statins, RRR about 25%) other preventive therapies, but without mortality benefits.9,10
Implementation
Although patients with CAD are generally at high risk of CV events, the 10-year risk varies from less than 10% to more than 40%.11 SMART12 and REACH13 scores can be used to estimate individual risk and the absolute benefits of colchicine. Colchicine could be offered to patients with CAD already taking standard secondary prevention medications with a discussion about the expected benefits, costs, and risks.
Notes
Tools for Practice articles in CFP are adapted from peer-reviewed articles at http://www.toolsforpractice.ca and summarize practice-changing medical evidence for primary care. Coordinated by Dr G. Michael Allan and Dr Adrienne J. Lindblad, articles are developed by the Patients, Experience, Evidence, Research (PEER) team and supported by the College of Family Physicians of Canada and its Alberta, Ontario, and Saskatchewan Chapters. Feedback is welcome at toolsforpractice{at}cfpc.ca.
Footnotes
Competing interests
None declared
The opinions expressed in Tools for Practice articles are those of the authors and do not necessarily mirror the perspective and policy of the Alberta College of Family Physicians.
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