Pseudogout Treatment
For acute pseudogout attacks, NSAIDs, colchicine, or corticosteroids are the recommended first-line treatments, with intra-articular or intramuscular corticosteroids being particularly effective and safe, especially in elderly patients or those with contraindications to NSAIDs. 1, 2
Acute Attack Management
First-Line Treatment Options
The treatment approach for acute pseudogout mirrors that of acute gout, with three primary medication classes 3:
NSAIDs: Standard doses of NSAIDs are effective for acute attacks, though caution is required in elderly patients due to gastrointestinal, renal, and cardiovascular risks 4, 1
Colchicine: Effective for acute pseudogout, though careful monitoring for toxicity is essential, particularly in elderly patients 4, 1
Corticosteroids: Multiple delivery routes are available and highly effective 1, 2:
- Intra-articular corticosteroids: Particularly useful for monoarticular attacks; very safe and effective 4, 2
- Intramuscular triamcinolone acetonide (60 mg): Demonstrated excellent efficacy in prospective studies, with major clinical improvement occurring by days 1-4 in most patients; safe and well-tolerated even in patients with NSAID contraindications 2
- Oral corticosteroids: Low-dose oral steroids are safe for short-term use and should be considered first-line in elderly patients 5, 4
Special Considerations for Elderly Patients
Intra-articular aspiration and injection of long-acting steroid is particularly safe and effective in elderly patients, avoiding systemic medication risks. 5
If intra-articular injection is not feasible, low-dose oral corticosteroids should be considered as first-line therapy due to their favorable safety profile 5
For polyarticular attacks where intra-articular injections are impractical, intramuscular corticosteroids provide an excellent alternative 2
Combination Therapy
For severe polyarticular attacks, combination therapy may be appropriate, though this is extrapolated from gout management guidelines 6:
- Acceptable combinations include colchicine with NSAIDs, or oral corticosteroids with colchicine 6
- Intra-articular steroids can be combined with other systemic modalities 6
Long-Term Management
Key Difference from Gout
Unlike gout, there is no standard regimen for long-term chronic therapies of pseudogout. 3
- Pseudogout does not have an equivalent to urate-lowering therapy used in gout management 3
- Long-term management focuses on treating underlying conditions and managing recurrent attacks 1
Supportive Measures
Topical ice packs: Can be used as adjuvant therapy for pain relief during acute flares 5
Address comorbidities: Management of hypertension, hyperlipidemia, and hyperglycemia is important 5
Diuretic management: If the patient is on diuretic therapy, consider stopping the diuretic if possible 5
Common Pitfalls to Avoid
Do not confuse pseudogout with gout: While acute treatment is similar, pseudogout does not respond to urate-lowering therapy 3
Avoid NSAIDs in high-risk elderly patients: Twelve of fourteen patients in one prospective study had contraindications to NSAIDs, highlighting the importance of corticosteroid alternatives 2
Consider polyarticular presentation: Pseudogout can involve multiple joints simultaneously, making systemic corticosteroids more practical than multiple intra-articular injections 2
Recognize atypical presentations: Pseudogout may present as chronic polyarthropathy resembling osteoarthritis or rheumatoid arthritis, particularly in geriatric patients 1