Colchicine has emerged as a promising anti-inflammatory option for secondary prevention in coronary artery disease, but its role in routine practice remains uncertain. Evidence from randomised trials suggests a more consistent benefit in chronic coronary syndromes and selected post-myocardial infarction populations. In contrast, results in acute coronary syndromes and PCI-related settings have been less convincing. This review summarises the main limitations and unresolved challenges of colchicine use in coronary artery disease, including heterogeneity across trials, lack of biomarker-guided patient selection, uncertainty regarding timing and duration of therapy, and concerns about tolerability, safety, and drug interactions. Current data suggest that colchicine may be useful in selected patients rather than as a universal treatment strategy. Further studies are needed to define its optimal clinical use better and to support a more personalised anti-inflammatory approach.