Colchicine may decrease cardiovascular events in patients with coronary artery disease
This oral anti-inflammatory agent may offer a low-cost option for prevention of cardiovascular events in this patient population.
PRACTICE CHANGER
Consider prescribing colchicine 0.5 mg daily as an addition to current standard-of-care therapies for patients with coronary artery disease (CAD) to prevent further cardiovascular events (CVEs).
STRENGTH OF RECOMMENDATION
B: Based on a single randomized controlled trial (RCT).1
Nidorf SM, Fiolet ATL, Mosterd A, et al; LoDoCo2 Trial Investigators. Colchicine in patients with chronic coronary disease. N Engl J Med. 2020;383:1838-1847.
The primary endpoint occurred less frequently in the colchicine group than in the placebo group (6.8% vs 9.6%; P < .001; number needed to treat = 36). The incidence rates for 2 of the individual outcomes in the composite, MI (hazard ratio [HR] = 0.7; 95% CI, 0.53-0.93) and ischemia-driven coronary revascularization (HR = 0.75; 95% CI, 0.60-0.94), were significantly lower in the colchicine group. The other outcomes were no different from placebo.1
There was a similar incidence of serious adverse events, such as noncardiovascular death, cancer diagnosis, and hospitalization for infection, pneumonia, or GI issues. High-dose statins were used by 3413 patients (61.8%). Myalgia (data collected only from the Netherlands cohort) was reported more commonly in the colchicine group than the placebo group (21.2% vs 18.5%; cumulative incidence ratio = 1.15; 95% CI, 1.01-1.31). Myotoxic effects were rare in both groups.1
WHAT’S NEW
RCT supports potential for anti-inflammatory therapy in CAD
This large RCT demonstrated that the addition of daily colchicine reduces CVE risk in patients with known CAD while maintaining a good safety profile.1
CAVEATS
Watch for potential drug interactions in patients with renal dysfunction
Prescribers should be aware of potential drug interactions, especially in those with renal or hepatic dysfunction, when prescribing colchicine, as it is metabolized through cytochrome P450 3A4 (CYP3A4) and excreted via the P-glycoprotein transport system, by which many statins are also metabolized and act as a competitive substrate.7 In addition, simvastatin, and to a lesser degree atorvastatin, are CYP3A4 inhibitors.
Also of note, the 0.5-mg colchicine tablet is not available in some countries—including the United States, where only 0.6-mg tablets are available. The 0.6-mg dose would likely have the same benefit and similar adverse effect profile but was not included in the study.
CHALLENGES TO IMPLEMENTATION
GI tolerability may be an issue
Colchicine is widely available and relatively low in cost, at approximately $32 per month for the 0.6-mg daily tablets. A major limitation is lack of tolerability, as adverse effects such as nausea, vomiting, diarrhea, and abdominal pain are frequently reported.
