What is the most appropriate treatment for a 72-year-old patient with symmetric polyarthritis of the wrists and metacarpophalangeal (MCP) joints, elevated erythrocyte sedimentation rate (ESR), and radiographic evidence of stippled linear calcium deposition, with laboratory results showing hyperglycemia, hypomagnesemia, and normal renal function?

From the Guidelines

The most appropriate treatment for this patient is colchicine. This patient presents with a clinical picture consistent with calcium pyrophosphate deposition disease (CPPD), also known as pseudogout. The diagnosis is supported by the symmetric polyarthritis affecting the wrists and MCP joints, previous self-limited episodes of knee swelling, and most importantly, the ultrasound and radiographic findings showing characteristic calcium deposits in the cartilage. The low magnesium level is also a risk factor for CPPD, as suggested by studies such as 1, which notes the potential for magnesium to solubilize CPP crystals and inhibit their formation. Colchicine is effective for both acute flares and prophylaxis of CPPD by reducing inflammation through inhibition of neutrophil chemotaxis and activity, as recommended by management guidelines for CPPD 1. The negative tests for rheumatoid factor, anti-CCP antibodies, and ANA help rule out other inflammatory arthritides. While acetaminophen might provide some symptomatic relief, it wouldn't address the underlying inflammatory process. Methotrexate would be excessive and inappropriate without evidence of rheumatoid arthritis. Prednisone could be considered for severe flares, but colchicine is preferred as initial therapy with fewer long-term side effects for this chronic condition.

Key Considerations

• The patient's clinical presentation and diagnostic findings are consistent with CPPD.
• Colchicine is the preferred initial treatment due to its efficacy in reducing inflammation and its relatively favorable side effect profile compared to other options like prednisone.
• Management of comorbidities, such as the patient's low magnesium level, is also important, as suggested by 1, which emphasizes the need to treat underlying conditions that may predispose to or exacerbate CPPD.
• The patient's age and comorbid conditions, including hypertension, gastroesophageal reflux, and prediabetes, should be considered when selecting a treatment to minimize potential adverse effects.

Treatment Approach

• Colchicine should be initiated as the first-line treatment for this patient's CPPD.
• Monitoring for potential side effects of colchicine and adjusting the dose as necessary is crucial.
• Consideration of magnesium supplementation may be beneficial given the patient's low magnesium level, as it may help in solubilizing CPP crystals, although direct evidence for its effectiveness in CPPD management is limited 1.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diagnosis and Treatment

The patient's symptoms and laboratory results suggest a diagnosis of calcium pyrophosphate deposition disease (CPPD), also known as chondrocalcinosis. The presence of hyperechoic linear intermittent deposits localized within the hyaline articular cartilage and stippled linear calcium deposition in the joint spaces on radiograph are characteristic of CPPD 2.

Treatment Options

The treatment options for CPPD include:

• Nonsteroidal anti-inflammatory drugs (NSAIDs) to control pain and inflammation
• Colchicine to treat acute flares
• Oral corticosteroids to reduce inflammation
• Methotrexate as a maintenance therapy to suppress acute flares 3, 4, 5
• Magnesium supplementation as a preventive measure 4

Appropriate Treatment

Given the patient's symptoms and laboratory results, the most appropriate treatment would be to control the acute inflammatory reaction and prevent further episodes. Colchicine is a commonly used treatment for acute CPP crystal arthritis and may be effective in this case 2, 5. However, considering the patient's age and comorbidities, methotrexate may also be a viable option as a maintenance therapy to suppress acute flares 3, 5.

Key Considerations

• The patient's low magnesium level may be a contributing factor to the development of CPPD, and magnesium supplementation may be beneficial 4
• The patient's hypertension, gastroesophageal reflux, and prediabetes should be taken into account when selecting a treatment option
• The patient's negative rheumatoid factor and anti-cyclic citrullinated peptide antibodies suggest that rheumatoid arthritis is unlikely, and the diagnosis of CPPD is more likely 2