What is the treatment for pseudogout?

Treatment of Pseudogout

The first-line treatment for acute pseudogout attacks includes oral colchicine, NSAIDs, or corticosteroids, with corticosteroids being preferred due to their safety profile and effectiveness when there are no contraindications. 1

Acute Attack Management

First-line options:

1. Corticosteroids

   • Preferred first-line therapy when no contraindications exist
   • Prednisolone 35 mg daily for 5 days is effective 1
   • Intra-articular injection of long-acting steroid is effective and safe for single joint involvement 1
   • Fewer adverse effects compared to NSAIDs

2. NSAIDs

   • Effective for pain relief in acute attacks
   • No evidence that indomethacin is superior to other NSAIDs 1
   • Contraindicated in patients with renal disease, heart failure, or cirrhosis

3. Colchicine

   • Low-dose regimen (1.2 mg followed by 0.6 mg 1 hour later) is as effective as higher doses with fewer gastrointestinal side effects 1
   • For maintenance: 0.6 mg twice daily 2
   • Contraindicated in patients with renal/hepatic impairment or those using cytochrome P450 3A4 inhibitors

Additional measures:

• Joint rest
• Ice application to affected joints
• Joint aspiration for diagnosis confirmation and symptom relief

Long-term Management

Indications for urate-lowering therapy:

• Recurrent attacks (≥2 per year)
• Presence of tophi
• Radiographic damage attributable to crystal deposition 1, 3

Urate-lowering options:

1. Xanthine oxidase inhibitors

   • Allopurinol: Start at 100 mg daily and increase by 100 mg every 2-4 weeks until target serum urate level is achieved 1, 3
   • Febuxostat: Alternative for patients who fail or cannot tolerate allopurinol 3

2. Uricosuric agents

   • Probenecid or sulfinpyrazone: For patients with normal renal function who cannot take xanthine oxidase inhibitors 1
   • Benzbromarone: Can be used in mild-moderate renal insufficiency but carries hepatotoxicity risk 1

3. Target serum urate level:

   • Maintain below 6 mg/dL (360 μmol/L) 1, 3
   • For severe tophaceous disease: below 5 mg/dL (300 μmol/L) 3

Prophylaxis during urate-lowering therapy:

• Low-dose colchicine (0.5-1 mg daily) or low-dose NSAIDs for 3-6 months after initiating therapy 1, 3
• Prevents mobilization flares during initial treatment

Special Considerations

Refractory cases:

• Consider IL-1 receptor antagonists (anakinra) for resistant cases 4
• Combination therapy may be needed in severe cases

Comorbidities:

• Adjust treatment based on renal function, cardiovascular disease, and other comorbidities
• In CKD patients:
  • Reduce colchicine dose
  • Prefer corticosteroids over NSAIDs
  • Adjust allopurinol dosing

Lifestyle modifications:

• Weight loss if obese
• Limit alcohol consumption, especially beer
• Adequate hydration
• Diet low in purine-rich foods

Monitoring

• Check serum urate levels every 2-4 weeks during dose titration
• Once target is achieved, monitor every 6 months
• Assess renal function regularly, especially in patients with CKD
• Monitor for adverse effects of medications

Treatment Pitfalls to Avoid

1. Using high-dose colchicine regimens, which cause excessive gastrointestinal side effects
2. Failing to provide prophylaxis when initiating urate-lowering therapy
3. Discontinuing urate-lowering therapy after acute attacks resolve
4. Not adjusting medication doses in patients with renal impairment
5. Confusing pseudogout with infection, especially in post-surgical settings 5

By following these evidence-based approaches, pseudogout can be effectively managed to reduce pain, prevent recurrent attacks, and improve quality of life.