Management of Pseudogout
For patients with pseudogout, first-line treatment includes oral NSAIDs, oral colchicine, or joint aspiration with corticosteroid injection for acute flares, while prophylactic low-dose colchicine (0.6 mg once or twice daily) is recommended for patients with recurrent attacks.
Acute Flare Management
First-line options:
- Oral NSAIDs with gastroprotection if indicated
- Low-dose colchicine: 1.2 mg immediately followed by 0.6 mg one hour later, with ongoing therapy until flare resolves
- Joint aspiration and intra-articular corticosteroid injection: Particularly effective for monoarticular flares and can provide rapid relief
Alternative options (when first-line treatments are contraindicated):
- Oral corticosteroids: 30-35 mg/day of prednisolone equivalent for 3-5 days
- Intramuscular or intravenous glucocorticoids: For patients unable to take oral medications
Adjunctive therapy:
- Topical ice: Can be used as an adjuvant treatment during acute flares 1
Prophylactic Treatment
Indications for prophylaxis:
- Recurrent attacks of pseudogout (≥2 attacks per year)
- When initiating treatments that might precipitate flares
Recommended prophylactic regimens:
- Low-dose colchicine: 0.6 mg once or twice daily, which has been shown to reduce pseudogout attacks from 3.2 to 1 per patient per year (p<0.001) 2
- Low-dose NSAIDs: If colchicine is not tolerated or contraindicated
Duration of prophylaxis:
- At least 6 months for patients with recurrent attacks
- Dose adjustment required in patients with renal impairment
Lifestyle Modifications
- Weight loss: Recommended for overweight/obese patients
- Dietary modifications:
- Limit alcohol intake, especially beer and spirits
- Reduce consumption of purine-rich foods
- Limit intake of high-fructose corn syrup and sugar-sweetened beverages
- Encourage consumption of low-fat dairy products 3
Special Considerations
Patients with renal impairment:
- Adjust colchicine dosage
- Avoid NSAIDs if possible
- Consider intra-articular corticosteroid injections as preferred treatment
Post-arthroplasty pseudogout:
- Important to distinguish from infection
- NSAIDs and cooling are effective treatments 4
- Consider prophylactic colchicine in patients with history of pseudogout undergoing arthroplasty
Monitoring
- Regular assessment of frequency of attacks
- Evaluation of response to treatment
- Monitoring of renal function in patients on colchicine or NSAIDs
Common Pitfalls to Avoid
- Misdiagnosis: Confusing pseudogout with gout or septic arthritis
- Inadequate prophylaxis: Not providing sufficient duration of prophylactic treatment
- Inappropriate dosing: Using high-dose colchicine which has similar efficacy but more adverse effects compared to low-dose regimens
- Overlooking comorbidities: Failing to adjust treatment based on renal function or other medical conditions
By following these guidelines, clinicians can effectively manage both acute pseudogout flares and provide appropriate prophylaxis for patients with recurrent attacks, significantly improving quality of life and reducing morbidity associated with this condition.