What is the recommended management for Calcium Pyrophosphate Deposition (CPPD) arthropathy?

Management of Calcium Pyrophosphate Deposition (CPPD) Arthropathy

For calcium pyrophosphate deposition (CPPD) arthropathy, the optimal treatment approach is joint aspiration followed by intra-articular long-acting glucocorticosteroid injection for acute monoarticular or oligoarticular attacks, combined with application of ice/cool packs and temporary rest of affected joints. 1

Acute CPPD Crystal Arthritis (Pseudogout)

First-line treatments:

• Joint aspiration + intra-articular glucocorticoid injection - Gold standard for monoarticular/oligoarticular attacks 1
• Oral NSAIDs with gastroprotection - Effective but limited by side effects in older patients 1
  • Contraindicated in renal impairment, cardiovascular disease, or GI risk
  • Always use with gastroprotection in at-risk patients
• Low-dose colchicine (0.5 mg up to 3-4 times daily) - NNT of 2 at 4 months for >30% pain reduction 2, 1
  • Avoid traditional high-dose regimens due to GI side effects
  • Side effects include diarrhea and other gastrointestinal symptoms

Alternative treatments (when NSAIDs/colchicine contraindicated):

• Systemic glucocorticoids - Particularly useful for polyarticular attacks 1
  • Options include:
    • Short tapering course of oral glucocorticoids
    • IV methylprednisolone (125 mg) - Provides rapid relief with NNT of 3 compared to oral NSAIDs 2, 1
    • IM betamethasone (7 mg) - Similar efficacy to IV methylprednisolone 2
    • ACTH - Safe and effective alternative 2

Prophylaxis for Recurrent Attacks

• Low-dose colchicine (0.6 mg twice daily) - Shown to reduce attack frequency from 3.2% to 1% per year 2
• Low-dose NSAIDs - Consider as alternative to colchicine 1
• Caution: Carefully weigh potential side effects, especially in elderly patients 2

Chronic CPP Crystal Inflammatory Arthritis

Treatment algorithm:

1. First-line: NSAIDs with gastroprotection or low-dose colchicine (0.5-1.0 mg daily) 2, 1
2. Second-line: Low-dose corticosteroids 1
3. Third-line options:
   • Methotrexate (5-10 mg/week) - Significant decrease in pain intensity and joint counts in refractory cases 2, 1
   • Hydroxychloroquine - NNT for clinical response of 2 (95% CI 1 to 7) 2
4. Emerging therapy: IL-1 inhibitors when other anti-inflammatory therapies are ineffective 1, 3

CPPD with Concurrent Osteoarthritis

• Follow same treatment objectives as for OA 2:

  • Educate patients about the condition and management
  • Reduce joint pain and stiffness
  • Maintain/improve joint mobility
  • Reduce physical disability
  • Improve quality of life
  • Limit joint damage progression

• Important caution: Avoid intra-articular high molecular weight hyaluronan as it might induce acute attacks 2

Special Considerations

• Age and comorbidities significantly impact treatment selection 1

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

• Underlying metabolic disorders should always be evaluated and treated 1, 4:

  • Hyperparathyroidism
  • Hemochromatosis
  • Hypomagnesemia
  • Hypophosphatemia

• Early-onset disease (before age 60) requires thorough metabolic workup, particularly for hemochromatosis 4

• Asymptomatic chondrocalcinosis requires no treatment 1

Treatment Limitations

• Unlike gout, there are currently no treatments to eliminate CPP crystal deposits 3, 5
• Limited high-quality evidence exists for CPPD treatment 6
• Most treatment approaches are based on clinical experience rather than controlled trials 7