Treatment of Pseudogout
The treatment of pseudogout should focus on NSAIDs, colchicine, or oral corticosteroids as first-line options for acute attacks, with colchicine prophylaxis recommended for recurrent episodes. 1
Acute Attack Management
First-line Options
- NSAIDs: Full dosing at FDA-approved anti-inflammatory doses (if no contraindications)
- Oral colchicine: Low-dose regimen of 1.2 mg initially, followed by 0.6 mg one hour later (total 1.8 mg) if started within 36 hours of symptom onset
- Corticosteroids: Oral prednisone (30-40 mg daily for 3-5 days, then taper) or intra-articular injection for 1-2 joint involvement
Severe or Polyarticular Attacks
For severe pain (≥7/10) or multiple joint involvement, combination therapy is appropriate:
- Colchicine + NSAIDs
- Oral corticosteroids + colchicine
- Intra-articular steroids with any other modality
NPO (Nil Per Os) Patients
For patients unable to take oral medications:
- Intra-articular corticosteroid injection for 1-2 joint involvement 2
- IV/IM methylprednisolone (0.5-2.0 mg/kg initially)
- Subcutaneous ACTH (25-40 IU initially)
Refractory Cases
For pseudogout resistant to conventional therapy:
- IL-1 inhibitors such as anakinra (100 mg subcutaneously daily for 3 days) may be effective 3
Prophylactic Treatment
Indications for Prophylaxis
- Recurrent attacks (≥2 per year)
- After resolution of an acute attack in patients with history of frequent recurrences
Prophylactic Regimens
Colchicine: 0.6 mg once or twice daily (first-line) 4
- Reduce dose in renal impairment
- Avoid with strong P-glycoprotein/CYP3A4 inhibitors
- Monitor for neurotoxicity in patients on statins
Low-dose NSAIDs: (e.g., naproxen 250 mg twice daily)
- Consider gastroprotection with PPI if indicated
Treatment Considerations and Precautions
Comorbidity Considerations
- Renal impairment: Avoid or reduce dose of NSAIDs and colchicine
- Cardiovascular disease: Use caution with NSAIDs
- Gastrointestinal issues: Avoid NSAIDs or use with gastroprotection
- Diabetes: Monitor glucose with corticosteroid use
- Infection risk: Use caution with corticosteroids
Adjunctive Measures
- Topical ice application to affected joints 2
- Rest and elevation of affected joints
- Joint aspiration for both diagnostic confirmation and therapeutic relief
Non-pharmacological Management
- Identification and treatment of underlying conditions (hyperparathyroidism, hemochromatosis, hypomagnesemia)
- Weight loss if overweight/obese
- Adequate hydration
Common Pitfalls to Avoid
- Delaying treatment beyond 24 hours of symptom onset
- Using high-dose colchicine regimens (continuing until GI side effects)
- Confusing pseudogout with infection, especially post-arthroplasty 5, 6
- Overlooking drug interactions with colchicine
- Inadequate duration of prophylactic therapy in recurrent cases
The treatment approach should be tailored based on attack severity, joint involvement, patient comorbidities, and previous response to therapy. Early intervention is crucial for optimal outcomes in managing pseudogout attacks.