What is the treatment for erosive changes in Calcium Pyrophosphate Deposition (CPPD) disease?

Treatment for Erosive Changes in CPPD Disease

For erosive changes in Calcium Pyrophosphate Deposition (CPPD) disease, treatment should follow the same approach as for osteoarthritis with CPPD, focusing on reducing inflammation, alleviating symptoms, and improving joint function through a combination of NSAIDs, colchicine, and disease-modifying agents in refractory cases. 1

First-Line Treatments

• NSAIDs should be used as initial therapy for chronic CPP crystal inflammatory arthritis with erosive changes, though evidence is extrapolated from gout and OA management. Always combine with gastroprotective agents (proton pump inhibitors) in high-risk patients or for long-term use 1

• Low-dose colchicine (0.5 mg twice daily) has demonstrated efficacy in a double-blind, placebo-controlled RCT for knee OA with persistent inflammation caused by CPPD, with an NNT of 2 (95% CI 1 to 4) at 4 months for pain reduction >30% 1

• Joint aspiration with intra-articular corticosteroid injection provides rapid relief for affected joints with significant inflammation 1

Second-Line Treatments for Refractory Cases

• Methotrexate (5-10 mg/week) should be considered for patients with erosive CPPD who are resistant to first-line treatments. An uncontrolled trial showed excellent clinical response in all treated patients with significant decrease in pain intensity (p<0.0001) and joint swelling/tenderness (p<0.0001) 1

• Hydroxychloroquine demonstrated efficacy in a 6-month double-blind, placebo-controlled RCT with an NNT of 2 (95% CI 1 to 7) for clinical response (>30% reduction in swollen/tender joint count) 1

• Low-dose oral glucocorticoids may be used for chronic inflammatory arthritis with CPPD when other treatments fail, though evidence is based primarily on expert opinion 1

Advanced Treatment Options

• IL-1 inhibitors (anakinra) should be considered for refractory erosive disease, as they target a key pathway in CPPD inflammation 2, 3

• Tocilizumab (IL-6 inhibitor) may be effective in severe cases unresponsive to other therapies 2, 4

• Intra-articular radiocolloid (yttrium-90) injection showed significant improvement for pain (NNT=2,95% CI 1 to 3) and global response in one small double-blind, placebo-controlled RCT for knee OA with CPPD, though not routinely recommended 1

Management of Associated Conditions

• Treat underlying metabolic conditions that may predispose to CPPD, such as hyperparathyroidism, hemochromatosis, or hypomagnesemia 1, 2

• Apply standard OA management principles including education, physical therapy, and joint protection strategies 1

Important Considerations and Pitfalls

• Avoid intra-articular high molecular weight hyaluronan as it might induce acute attacks in patients with CPPD 1

• No disease-modifying therapies currently exist that can dissolve or reduce CPP crystal deposition, unlike treatments for gout 2, 5, 4

• Carefully consider comorbidities and age when selecting treatments, as CPPD predominantly affects older patients who may have contraindications to certain medications 1

• Monitor for side effects of long-term treatments, particularly with NSAIDs, colchicine, and methotrexate 1