What is the management of calcium pyrophosphate deposition disease (CPPD), also known as pseudogout, in an 89-year-old female (F)?

From the Guidelines

Management of pseudogout in an 89-year-old female should prioritize pain relief and reducing inflammation, focusing on non-pharmacological and pharmacological modalities tailored to her clinical features, age, and comorbidities. According to the EULAR recommendations for calcium pyrophosphate deposition disease (CPPD) management 1, the optimal treatment approach should be individualized. For acute CPP crystal arthritis, application of ice or cool packs, temporary rest, joint aspiration, and intra-articular injection of long-acting glucocorticosteroids (GCS) are recommended as first-line treatments 1.

In terms of pharmacological management, low-dose oral colchicine (0.5 mg up to 3-4 times a day) or oral NSAID (with gastroprotective treatment if indicated) can be effective systemic treatments for acute CPP crystal arthritis 1. However, considering the patient's advanced age, NSAIDs should be used with caution due to the increased risk of gastrointestinal bleeding, renal impairment, and cardiovascular events.

For chronic CPP crystal inflammatory arthritis, pharmacological options in order of preference are oral NSAID (plus gastroprotective treatment if indicated) and/or colchicine (0.5-1.0 mg daily), low-dose corticosteroid, methotrexate, and hydroxychloroquine 1. It is essential to address any underlying conditions, such as hyperparathyroidism or hemochromatosis, if present 1. Regular monitoring of renal function and adjusting medication dosages accordingly are crucial in this age group.

Key considerations in managing pseudogout in this patient include:

• Avoiding NSAIDs due to age-related risks
• Using colchicine with caution and at low doses
• Considering intra-articular GCS injections for localized joint involvement
• Addressing underlying metabolic disorders
• Monitoring renal function and adjusting medication dosages as needed
• Focusing on non-pharmacological modalities, such as joint protection, physical therapy, and assistive devices, to maintain function.

From the Research

Management of Calcium Pyrophosphate Deposition Disease (CPPD)

The management of CPPD, also known as pseudogout, in an 89-year-old female patient can be challenging due to the presence of comorbidities and polypharmacy.

• Treatment options for CPPD include:
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) 2
  • Colchicine 2, 3, 4, 5
  • Corticosteroids 2, 3, 4, 5
• It is essential to consider the patient's comorbidities and potential drug interactions when selecting a treatment option 3, 4, 5.
• Intra-articular corticosteroid injection may be considered for accessible joints 4.
• Urate-lowering agents, such as allopurinol, may be used to prevent gout flares, but require careful selection and dosing in older adults with renal impairment 3, 5.

Considerations in Older Adults

• Older adults with CPPD may have atypical presentations, making diagnosis challenging 3, 6.
• Comorbidities, such as chronic kidney disease, peptic ulcer disease, and congestive heart failure, may limit treatment options 3, 4, 5.
• Polypharmacy may increase the risk of drug interactions and adverse effects 3, 4, 5.
• It is crucial to monitor the patient's response to treatment and adjust the treatment plan as needed 2, 3, 4, 5.