What is the treatment for pseudogout?

Treatment for Pseudogout

The treatment of pseudogout should include NSAIDs, colchicine, or corticosteroids for acute attacks, with the choice depending on patient comorbidities and contraindications. 1

Acute Attack Management

First-line Treatment Options

• NSAIDs at full anti-inflammatory doses are effective first-line agents for acute pseudogout attacks when there are no contraindications 1
• Low-dose colchicine (0.5-0.6 mg two to three times daily) is effective and has fewer gastrointestinal side effects than traditional high-dose regimens 1
• Corticosteroids are particularly useful in patients with contraindications to NSAIDs and should be considered as first-line therapy due to their favorable safety profile 1, 2
• Intra-articular aspiration and injection of long-acting steroids is an effective and safe treatment for acute pseudogout affecting accessible joints 1

Treatment Selection Algorithm

1. For mild/moderate attacks affecting 1-3 small joints or 1-2 large joints:

   • Start with monotherapy using NSAIDs, colchicine, or corticosteroids 1
   • Consider patient comorbidities when selecting therapy:
     • Avoid NSAIDs in patients with renal disease, heart failure, or cirrhosis 1
     • Avoid colchicine in patients with renal or hepatic impairment 1
     • Consider corticosteroids in patients with contraindications to both NSAIDs and colchicine 1, 2

2. For severe polyarticular attacks:

   • Combination therapy may be appropriate 1
   • Systemic corticosteroids (prednisone 0.5 mg/kg/day for 5-10 days) are particularly effective 1

Long-term Management

Prophylaxis

• For patients with frequent recurrent attacks, prophylactic therapy can be considered 1:
  • Low-dose colchicine (0.5-0.6 mg once or twice daily) 1, 3
  • Low-dose NSAIDs with gastric protection if indicated 1, 3
  • Low-dose corticosteroids (<10 mg/day) if colchicine and NSAIDs are contraindicated 1

Associated Conditions

• Unlike gout, there are no agents available that have been shown to decrease crystal load in pseudogout 4
• Address underlying metabolic or endocrine conditions that may be associated with pseudogout 4
• If pseudogout is associated with diuretic therapy, consider stopping the diuretic if possible 1

Patient Education and Lifestyle Modifications

• Patient education about the condition and appropriate lifestyle advice are core aspects of management 1
• Recommend weight loss if obese, appropriate diet modifications, and reduced alcohol consumption 1
• Address associated comorbidities such as hyperlipidemia, hypertension, and hyperglycemia 1

Common Pitfalls and Caveats

• High doses of colchicine lead to significant gastrointestinal side effects; low doses are generally sufficient and better tolerated 1
• When initiating treatment, start within 24 hours of symptom onset for optimal efficacy 1
• NSAIDs carry risks of gastrointestinal bleeding and cardiovascular toxicity, particularly in elderly patients 1, 2
• Unlike gout, pseudogout does not have established urate-lowering therapy options, making management of recurrent attacks more challenging 5, 4
• Pseudogout can be confused with degenerative osteoarthritis, making proper diagnosis through crystal identification important for appropriate treatment 6