Colchicine is an effective and relatively specific treatment for acute gout and has a long, venerable history. Serious toxic reactions to colchicine could be prevented if guidelines for its use were followed strictly, but because of its relatively infrequent use and conflicting recommendations, considerable toxic effects might occur and still be undetected by passive surveillance. A review of a teaching hospital's four years' experience showed two deaths (2% incidence) due to inappropriate use. Colchicine has the smallest benefit-to-toxicity ratio of drugs that are effective for acute gout. This article gives specific recommendations for the use of colchicine in different clinical settings.