Death and morbidity from supratherapeutic dosing of colchicine

To the Editor: We agree with Smith and colleagues1 that it is important to raise awareness among health professionals — and consumers — about recently revised dosing recommendations for colchicine. Software decision-support tools have an important role in ensuring safe prescribing of such drugs. However, we have questions about whether this software uses information that is up-to-date with current evidence, particularly in relation to colchicine.

We believe that the clinical software systems used by clinicians and pharmacists could better support them in relation to medicines safety issues like this one. First, they could provide up-to-date, evidence-based dosing information. Second, they could warn the user when potentially harmful drug doses are being prescribed or dispensed, or when there are new recommendations about drug therapy. In this case, the situation is not straightforward because there are inconsistencies in the dosing recommendations for colchicine.

In 2010, an article in NPS RADAR highlighted new evidence to support the use of low-dose colchicine in acute gout.2 This new dosage regimen was also recommended in the Australian medicines handbook in 2010.3 Nevertheless, higher doses are currently recommended in the Australian approved product information (PI), the consumer medicines information leaflet, and other commonly used medicine reference sources (this raises other issues, including the fact that there is currently no process to ensure that the PI is regularly reviewed, and the role of the Therapeutic Goods Administration4; however, these are beyond the scope of this letter).

There is no guidance for clinical software vendors regarding which information to provide, and, at present, drug dosage information in these systems is frequently based on the PI as provided by the manufacturer or sponsor. We examined colchicine dosing information provided at (or accessible from) the point of prescribing or dispensing in a number of commonly used systems, and none showed the recent low-dose recommendations. Nor were any alerts or warnings displayed about potential toxicity specifically related to the dosage regimen for colchicine.

Our previous research has shown that, in general, there is little of this type of decision support available in general practice software.5 Guidance for software vendors and high-quality, up-to-date knowledge bases are required to support this functionality. Currently, there is no overarching governance mechanism in Australia to guide the development of decision support, or to ensure that the inclusion of clinical information in software is up-to-date or based on the latest evidence. A coordinated approach to ensure that these systems support safety and quality is long overdue.6