What are the treatment options for Calcium Pyrophosphate Deposition Disease (CPPD)?

Treatment Options for Calcium Pyrophosphate Deposition Disease (CPPD)

For optimal management of CPPD, treatment must be tailored according to clinical presentation (asymptomatic chondrocalcinosis, acute CPP crystal arthritis, or chronic inflammatory arthritis), patient factors (age, comorbidities), and presence of any underlying metabolic disorders. 1, 2

Acute CPP Crystal Arthritis Treatment

First-line Treatment

• Application of ice or cool packs, temporary rest, joint aspiration, and intra-articular injection of long-acting glucocorticosteroids are optimal and safe first-line treatments for acute attacks 1, 2
• For monoarticular or oligoarticular attacks, joint aspiration with intra-articular glucocorticosteroid injection is highly effective and should be performed when possible 2

Systemic Treatment Options

• Low-dose oral colchicine (0.5 mg up to 3-4 times daily with or without an initial dose of 1 mg) is effective for acute attacks, though traditional high-dose regimens should be avoided due to 100% incidence of marked side effects 1
• Oral NSAIDs with gastroprotective treatment (if indicated) are effective but use is often limited by toxicity and comorbidities, especially in older patients 1, 3
• A short tapering course of oral glucocorticosteroids, parenteral glucocorticosteroids, or ACTH may be effective for acute CPP crystal arthritis not amenable to intra-articular injection and serve as alternatives to colchicine/NSAIDs 1, 2

Prophylaxis Against Recurrent Attacks

• Low-dose oral colchicine (0.5-1 mg daily) can effectively prevent recurrent acute CPP crystal arthritis 1, 3
• Low-dose oral NSAIDs with gastroprotection (if indicated) are also effective for prophylaxis 1, 2

Chronic CPP Crystal Inflammatory Arthritis

• First-line pharmacological options (in order of preference): oral NSAIDs with gastroprotection and/or colchicine (0.5-1.0 mg daily) 1, 4
• Second-line options: low-dose corticosteroids, methotrexate, and hydroxychloroquine 1, 5
• For refractory cases, biologics targeting IL-1 (anakinra) or IL-6 (tocilizumab) may be considered 3, 6

Management of Associated Conditions

• If detected, associated conditions such as hyperparathyroidism, hemochromatosis, or hypomagnesemia should be treated 2, 7
• Treatment of these underlying conditions may help prevent further crystal deposition but will not dissolve existing crystals 5

Special Considerations

• Asymptomatic chondrocalcinosis requires no treatment 8, 7
• Management objectives and treatment options for patients with osteoarthritis and CPPD are the same as those for osteoarthritis without CPPD 1
• Currently, no treatment modifies CPP crystal formation or dissolution 8, 5

Common Pitfalls and Caveats

• Intravenous colchicine should be avoided due to high risk of serious toxicity and potential fatality 1, 2
• Treatment selection must carefully consider patient age and comorbidities, as CPPD predominantly affects older patients who often have chronic renal impairment and other conditions that increase risk of medication toxicity 1, 2
• Joint aspiration should always be performed when possible to confirm diagnosis and exclude infection before administering intra-articular steroids 1, 4
• Despite being one of the most common forms of inflammatory arthritis, CPPD remains under-studied with limited high-quality evidence for treatment 4, 6