What is the recommended treatment for pseudogout?

Treatment of Pseudogout

For pseudogout treatment, first-line therapy includes NSAIDs with gastric protection, low-dose colchicine, or corticosteroids, with colchicine 0.6 mg twice daily showing significant effectiveness as prophylaxis for recurrent attacks. 1

Acute Attack Management

First-line options:

• NSAIDs with gastric protection 2, 3

  • Example: Naproxen 250 mg twice daily
  • Use with caution in patients with hypertension, diabetes, renal impairment, or history of peptic ulcer disease

• Low-dose colchicine 2, 3

  • Dosing: 0.6 mg once or twice daily (0.5 mg once or twice daily outside US)
  • Most effective when started within 12 hours of symptom onset
  • Loading dose of 1 mg followed 1 hour later by 0.5 mg on day 1 for acute attacks

• Corticosteroids 2, 3

  • Oral prednisolone 30-35 mg/day for 3-5 days
  • Intra-articular steroid injections for monoarticular involvement
  • Preferred in elderly patients or those with contraindications to NSAIDs/colchicine

Combination therapy for severe attacks:

For severe attacks, particularly with polyarticular involvement, combination therapy may be appropriate 2:

• Colchicine + NSAIDs
• Oral corticosteroids + colchicine
• Intra-articular steroids + any other modality

Prophylactic Treatment

A study specifically examining colchicine prophylaxis in pseudogout demonstrated that colchicine 0.6 mg twice daily reduced attack frequency from 3.2 to 1.0 attacks per patient per year, with 90% of patients benefiting from this regimen 1. This represents the most recent evidence specifically for pseudogout prophylaxis.

Duration of prophylaxis:

• At least 3-6 months, depending on clinical response
• May require longer treatment in patients with frequent recurrences

Special Considerations for Elderly Patients

Elderly patients require special attention when treating pseudogout 4:

• NSAIDs: Use with extreme caution; prefer those with shorter half-lives (diclofenac, ketoprofen)
• Colchicine: Often poorly tolerated in the elderly; consider lower doses
• Corticosteroids: May be preferred in elderly patients with medical comorbidities

Treatment Pitfalls and Caveats

1. Medication adjustments for renal impairment:

   • Reduce colchicine dose in renal insufficiency
   • Avoid NSAIDs in moderate to severe renal impairment

2. Addressing underlying factors:

   • Consider discontinuing medications that may contribute (thiazide diuretics)
   • For hypertension, consider losartan which has uricosuric effects 2

3. Monitoring:

   • Regular follow-up to assess treatment response
   • Adjust therapy based on frequency and severity of attacks

4. Long-term management:

   • Unlike gout, there is no standard regimen for long-term management of pseudogout 5
   • Prophylactic colchicine may be beneficial for patients with recurrent attacks 1

5. Surgical management:

   • Reserved for cases with significant joint destruction or when diagnosis is uncertain 6

The evidence strongly supports using colchicine prophylaxis for recurrent pseudogout attacks, with a significant reduction in attack frequency demonstrated in research specifically examining pseudogout 1. When selecting acute treatment, consider patient comorbidities, medication interactions, and prior response to therapy.