Management of Pseudogout (Calcium Pyrophosphate Deposition Disease)
For acute pseudogout attacks, joint aspiration with intra-articular corticosteroid injection is the preferred first-line treatment for monoarticular or oligoarticular disease, providing rapid symptom relief; alternatively, oral NSAIDs, low-dose colchicine, or oral corticosteroids are effective options. 1
Acute Attack Management
First-Line Treatments
Joint aspiration combined with intra-articular long-acting glucocorticosteroid injection is recommended as the optimal approach for monoarticular or oligoarticular pseudogout attacks, as it provides both diagnostic confirmation and immediate therapeutic benefit. 1
For patients where joint injection is not feasible or for polyarticular disease:
Oral NSAIDs are effective first-line agents, dosed similarly to acute gout treatment (e.g., naproxen 500 mg twice daily, indomethacin 50 mg three times daily). 1
Low-dose colchicine (0.5 mg three to four times daily, with or without a 1 mg loading dose) is recommended to minimize gastrointestinal side effects while maintaining efficacy. 1 This is substantially lower than traditional high-dose regimens that caused severe adverse effects. 1
Oral corticosteroids (e.g., prednisone 30-40 mg daily with taper over 7-10 days) are effective for patients with contraindications to NSAIDs and colchicine. 1
Adjunctive Measures
- Application of ice or cool packs and temporary rest of the affected joint(s) help reduce inflammation and pain. 1
Alternative Therapies
- IL-1 blockers may be considered for patients with contraindications to colchicine, NSAIDs, and corticosteroids, though this extrapolates from gout management data. 1
Prophylactic Treatment for Recurrent Attacks
For patients with frequent recurrent pseudogout attacks, prophylactic low-dose colchicine (0.5-1 mg daily) should be considered. 1
NSAIDs at lower doses can also be used for prophylaxis in patients who tolerate them well and have a history of recurrent attacks. 1
Unlike gout, there is no crystal-lowering therapy available for pseudogout, as the disease involves calcium pyrophosphate crystals rather than uric acid. 1 This is a critical distinction—do not prescribe allopurinol or other urate-lowering agents for pseudogout.
Management of Chronic CPPD
Treatment should be individualized based on clinical presentation, severity, and comorbidities. 1
For patients with CPPD-associated osteoarthritis:
Standard osteoarthritis management approaches should be employed, including physical therapy and appropriate exercise programs. 1
Weight loss if overweight or obese is recommended. 1
Analgesics for pain control should be used as needed. 1
Special Considerations and Metabolic Workup
In patients with pseudogout secondary to metabolic disorders (hyperparathyroidism, hemochromatosis, hypomagnesemia), treating the underlying condition is essential. 1 Screen for these conditions, particularly in younger patients (<60 years) or those with polyarticular disease.
Critical Safety Considerations
Medication Contraindications
Colchicine and NSAIDs should be avoided in patients with severe renal impairment (eGFR <30 mL/min). 1
Colchicine should not be given to patients receiving strong P-glycoprotein and/or CYP3A4 inhibitors, such as cyclosporine or clarithromycin, due to risk of severe toxicity. 1
Common Pitfalls to Avoid
Overuse of colchicine with traditional high-dose regimens can lead to severe gastrointestinal side effects, including life-threatening diarrhea and dehydration; always use lower doses. 1
Long-term NSAID use carries significant risks, particularly in elderly patients who commonly develop pseudogout, including gastrointestinal bleeding, renal impairment, and cardiovascular complications. 1 Consider gastroprotection with proton pump inhibitors in high-risk patients.
Failing to screen for associated comorbidities and cardiovascular risk factors can lead to inadequate management and should be addressed as part of comprehensive care. 1
Do not prescribe urate-lowering therapy (allopurinol, febuxostat) for pseudogout—this is ineffective and represents a fundamental misunderstanding of the disease pathophysiology. 1
Patient Education
Patients with pseudogout should be fully informed about the pathophysiology of the disease, available treatments, associated comorbidities, and management principles. 1 Patient education should include lifestyle advice such as weight loss if appropriate, regular exercise, and dietary modifications. 1