What is the treatment for pseudogout?

Treatment for Pseudogout

The first-line treatment for acute pseudogout attacks consists of oral NSAIDs, oral colchicine, or systemic corticosteroids, with the choice depending on pain severity, number of joints involved, and patient comorbidities. 1, 2

Acute Attack Management

First-line Options:

1. NSAIDs:

   • Full FDA/EMA approved dosing (e.g., naproxen, indomethacin)
   • Most effective when started early in the attack
   • Cautions: Avoid in patients with renal impairment, heart failure, peptic ulcer disease, or those on anticoagulants 1, 2

2. Colchicine:

   • Low-dose regimen: 1.2 mg initially, followed by 0.6 mg one hour later 2
   • Most effective when started within 12 hours of symptom onset
   • Cautions: Adjust dose in renal impairment, avoid with strong P-glycoprotein/CYP3A4 inhibitors 2

3. Corticosteroids:

   • Oral prednisone (30-35 mg daily for 3-5 days)
   • Intra-articular injection for 1-2 affected joints
   • Intramuscular/intravenous methylprednisolone (0.5-2.0 mg/kg) 1, 2
   • Advantage: Better safety profile than NSAIDs for GI effects 3

For NPO Patients:

• Intra-articular corticosteroid injection (for 1-2 joints)
• IV/IM methylprednisolone (0.5-2.0 mg/kg)
• Subcutaneous ACTH (25-40 IU) 1

For Severe/Refractory Cases:

• Combination therapy (e.g., colchicine plus NSAIDs) 1
• Consider IL-1 inhibitors like anakinra in treatment-resistant cases 4, 5

Adjunctive Therapy:

• Topical ice application 1

Prophylactic Treatment

For patients with recurrent pseudogout attacks:

• Low-dose colchicine (0.6 mg once or twice daily) has been shown to reduce attack frequency from 3.2 to 1 attacks per patient per year 6
• Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI if indicated 1, 2
• Continue prophylaxis for at least 8 weeks when initiating treatment 2

Lifestyle Modifications

• Weight loss if obese
• Limit alcohol consumption (especially beer)
• Adequate hydration (at least 2 liters daily)
• Regular moderate physical activity 2

Management of Associated Conditions

• For hypertension: Consider losartan (has uricosuric effects)
• For hyperlipidemia: Consider fenofibrate (has modest uricosuric effects) 1, 2
• Address other metabolic conditions that may be associated with pseudogout

Monitoring and Safety Considerations

• Assess renal function before initiating therapy
• Monitor for GI side effects with NSAIDs (dyspepsia, abdominal pain, diarrhea)
• Watch for colchicine toxicity in patients with renal impairment
• Evaluate for drug interactions, particularly with colchicine 2

Treatment Algorithm

1. Assess patient factors: Comorbidities, contraindications, prior response
2. For mild/moderate attacks (≤6/10 pain, 1-3 small joints or 1-2 large joints): Choose one first-line agent
3. For severe/polyarticular attacks: Consider combination therapy
4. For patients with frequent recurrences: Implement prophylactic therapy
5. For all patients: Implement appropriate lifestyle modifications

Unlike gout, there are currently no medications proven to decrease crystal load in pseudogout, so treatment focuses primarily on managing inflammation and preventing recurrent attacks 5.