What is the treatment approach for crystalline arthropathy?

Treatment Approach for Crystalline Arthropathy

The optimal treatment for crystalline arthropathy, particularly calcium pyrophosphate deposition disease (CPPD), requires joint aspiration and intra-articular glucocorticoid injection as first-line treatment for acute attacks, followed by tailored pharmacological options based on clinical presentation. 1

Acute Attack Management

First-Line Treatment

• Joint aspiration and intra-articular long-acting glucocorticosteroid injection
  • Most effective and safest approach for acute monoarticular or oligoarticular attacks 2, 1
  • High strength of recommendation (SOR: 95%) 2
  • Should be combined with:
    • Application of ice/cool packs to affected joints
    • Temporary rest of affected joints

Systemic Treatments (when intra-articular injection not feasible)

1. NSAIDs with gastroprotection

   • Effective but limited by side effects in older patients
   • Contraindicated in renal impairment, cardiovascular disease, or GI risk
   • Side effects include GI bleeding, cardiovascular events, renal impairment 2

2. Low-dose oral colchicine

   • Dosing: 0.5 mg up to 3-4 times daily (with or without initial 1 mg loading dose) 2, 1
   • Avoid traditional high-dose regimens (associated with 100% incidence of side effects) 2
   • Main side effect: diarrhea

3. Systemic glucocorticoids

   • Options when NSAIDs/colchicine contraindicated:
     • Short tapering course of oral glucocorticoids
     • Parenteral glucocorticoids (IV methylprednisolone 125 mg or IM betamethasone 7 mg)
     • ACTH (adrenocorticotrophic hormone)
   • NNT of 3 compared to oral NSAIDs for rapid relief 1
   • Particularly useful for polyarticular attacks 2

Prophylaxis for Recurrent Attacks

For patients with frequent recurrent acute CPP crystal arthritis:

• Low-dose oral colchicine (0.5-1 mg daily) 2, 1
• Low-dose oral NSAIDs with gastroprotection if indicated 2

Chronic CPP Crystal Inflammatory Arthritis Management

Pharmacological options in order of preference:

1. Oral NSAIDs with gastroprotection if indicated
2. Low-dose colchicine (0.5-1.0 mg daily)
   • NNT of 2 (95% CI 1 to 4) at 4 months for >30% pain reduction 2, 1
3. Low-dose corticosteroids
4. Methotrexate (5-10 mg/week)
   • Particularly for patients resistant to common treatments
   • Significant decrease in pain intensity and joint counts reported 2, 1
5. Hydroxychloroquine
   • NNT for clinical response: 2 (95% CI 1 to 7) 2

Management of Associated Conditions

If detected, treat associated conditions:

• Hyperparathyroidism
• Hemochromatosis
• Hypomagnesemia

Treatment of these underlying conditions is required but may not necessarily affect CPPD-associated arthritis outcomes 2.

Important Considerations

• Age and comorbidities significantly impact treatment selection:

  • Elderly patients have higher risk of toxicity with NSAIDs and colchicine
  • Renal impairment increases risk of adverse effects

• No treatment currently modifies CPP crystal formation or dissolution - management focuses on controlling inflammation and symptoms 2, 1

• Asymptomatic chondrocalcinosis requires no treatment 2

• Allopurinol is NOT indicated for CPPD - it is for gout (urate crystal disease) only 3

Treatment Algorithm

1. Acute attack:

   • Monoarticular/oligoarticular → Joint aspiration + intra-articular glucocorticoid
   • If not feasible → NSAIDs (if no contraindications) OR colchicine (if NSAIDs contraindicated) OR systemic glucocorticoids (if both contraindicated)

2. Recurrent attacks:

   • Low-dose colchicine prophylaxis OR low-dose NSAID prophylaxis

3. Chronic inflammatory arthritis:

   • Start with NSAIDs/colchicine → If ineffective → Low-dose corticosteroids → If still ineffective → Methotrexate or hydroxychloroquine

4. Always treat underlying metabolic disorders if present

This approach prioritizes patient safety while effectively managing both acute attacks and chronic inflammation to reduce morbidity and improve quality of life.