What is the treatment for a pseudo gout (calcium pyrophosphate deposition disease) flare?

Treatment of Pseudogout Flares

The first-line treatment options for pseudogout (calcium pyrophosphate deposition disease) flares include oral NSAIDs, colchicine, and oral or intra-articular corticosteroids, with the choice based on patient factors, comorbidities, and timing of treatment initiation. 1, 2

First-Line Treatment Options

• Oral NSAIDs at full FDA-approved doses are recommended as a first-line treatment option for pseudogout flares, particularly when started early in the course of the flare 1, 2
• Colchicine is most effective when given within 12 hours of symptom onset at a loading dose of 1.2 mg followed by 0.6 mg one hour later on day 1 2, 3
• Oral corticosteroids (prednisone/prednisolone 30-35 mg daily for 3-5 days) are recommended, particularly for patients with contraindications to NSAIDs or colchicine 1, 2
• Joint aspiration and intra-articular corticosteroid injection is highly effective for monoarticular or oligoarticular pseudogout flares, especially for large accessible joints 1
• Temporary rest and application of ice or cool packs to the affected joint can provide additional symptomatic relief 1

Treatment Selection Considerations

• Early treatment initiation is crucial for optimal effectiveness; the "pill in the pocket" approach is recommended for fully informed patients to self-medicate at the first warning symptoms 1, 2
• For patients with particularly severe acute pseudogout involving multiple joints, combination therapy can be considered 1, 2
• For patients unable to take oral medications, parenteral glucocorticoids (intramuscular, intravenous, or intra-articular) are strongly recommended 1, 2

Special Considerations and Contraindications

• Colchicine should be avoided in patients with severe renal impairment (GFR <30 mL/min) 3
• Colchicine dose should be reduced in patients taking strong P-glycoprotein and/or CYP3A4 inhibitors 3
• NSAIDs should be used with extreme caution in elderly patients and those with peptic ulcer disease, renal failure, uncontrolled hypertension, or cardiac failure 1, 4
• For patients with renal impairment requiring colchicine, dose adjustment is necessary according to creatinine clearance levels 3

Treatment Algorithm

1. For monoarticular or oligoarticular pseudogout affecting accessible joints:

   • Joint aspiration followed by intra-articular corticosteroid injection is the preferred approach 1

2. For polyarticular pseudogout or inaccessible joints:

   • If within 12 hours of symptom onset: Colchicine 1.2 mg followed by 0.6 mg one hour later 2, 3
   • If beyond 12 hours of symptom onset or colchicine contraindicated: NSAIDs at full dose or oral prednisone 30-35 mg daily for 3-5 days 1, 2

3. For patients with contraindications to both NSAIDs and colchicine:

   • Oral prednisone 0.5 mg/kg per day for 5-10 days 2
   • Alternatively, intramuscular or intravenous corticosteroids 1, 2

Common Pitfalls and Caveats

• Failing to start treatment early significantly reduces effectiveness; acute pseudogout should be treated as soon as possible 1, 2
• Using traditional high-dose colchicine regimens (1 mg loading dose followed by 0.5 mg every 2 hours until side effects develop) can lead to 100% incidence of marked side effects; lower-dose regimens are now recommended 1
• Overlooking the need for dose adjustments in patients with renal or hepatic impairment can lead to toxicity 3
• Treating only the acute flare without addressing modifiable risk factors (if present) may lead to recurrent attacks 1

Monitoring and Duration

• Continue treatment until the pseudogout attack has completely resolved 2
• A 3-5 day course at full dose is typically sufficient for oral corticosteroids 2
• Monitor for potential adverse effects, particularly in elderly patients who may be more susceptible to medication side effects 4