From the Guidelines
The diagnostic approach for pseudogout involves joint fluid analysis to identify calcium pyrophosphate dihydrate (CPPD) crystals, which appear rhomboid-shaped and weakly positively birefringent under polarized light microscopy. X-rays may show chondrocalcinosis (calcification of cartilage). Treatment focuses on managing acute attacks and preventing recurrences. For acute attacks, joint aspiration to remove inflammatory fluid provides immediate relief, followed by pharmacological management.
Key Points:
- NSAIDs like naproxen (500mg twice daily) or indomethacin (25-50mg three times daily) for 7-14 days are first-line treatments.
- For patients with contraindications to NSAIDs, colchicine (0.6mg once or twice daily) can be effective if started early.
- Corticosteroids are alternatives, either as intra-articular injections (e.g., methylprednisolone 40-80mg) or oral prednisone (30-40mg daily with taper over 7-10 days).
- For prophylaxis in recurrent cases, low-dose colchicine (0.6mg daily) or low-dose NSAIDs may be used.
- Addressing underlying conditions like hyperparathyroidism, hemochromatosis, or hypothyroidism is crucial as these can contribute to CPPD crystal formation.
- Joint protection, physical therapy, and weight management are important supportive measures to reduce joint stress and prevent further damage, as noted in studies such as 1 and 1.
From the Research
Diagnostic Approach
- The diagnosis of pseudogout involves synovial fluid aspiration and microscopic synovial fluid analysis under compensated polarized light to confirm the suspicion of crystal-induced arthropathy 2.
- Underlying diseases should always be sought, as many are treatable 2.
- Pseudogout can be confused with other arthritic disorders, such as gout, and a thorough diagnosis is necessary to distinguish between them 3.
- Imaging studies, such as CT scans, can also be used to diagnose pseudogout, particularly in cases of tophaceous pseudogout 4.
Treatment
- Treatment for pseudogout includes the use of nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids 3, 5.
- Intra-articular or systemic glucocorticoids can be effective in treating pseudogout, but should be used in small amounts if use is prolonged 5.
- Colchicine can be effective in treating recurring pseudogout 5.
- Magnesium can be effective on a preventive basis 5.
- Methotrexate has shown interesting effectiveness in a small, uncontrolled series, and can be used in the event of failure of other treatments 5.
- Dietary factors, weight reduction, and avoidance of certain forms of alcohol may also impact the treatment of pseudogout, particularly in cases of gout 3.
- Uric acid-lowering agents can be effective for refractory or chronic tophaceous disease 3.
Clinical Presentations
- Pseudogout can present as acute mono- or oligoarticular disease, or as a chronic polyarthropathy resembling osteoarthritis or rheumatoid arthritis 3.
- Pseudogout in the geriatric patient has a variety of clinical presentations, and should be considered in evaluating any patient with osteoarthritis occurring in an atypical distribution 3.
- Tophaceous pseudogout is a rare and tumoral form of pseudogout, which can involve the hip joint and other areas 4.
- Pseudogout can be associated with underlying metabolic diseases, such as primary hyperparathyroidism or idiopathic hemochromatosis 6.