What is the recommended treatment for pseudogout?

Treatment of Pseudogout

For acute pseudogout attacks, NSAIDs at full anti-inflammatory doses are first-line when there are no contraindications, while low-dose oral corticosteroids or intra-articular steroid injection should be prioritized in elderly patients or those with NSAID contraindications. 1

Acute Attack Management

First-Line Options Based on Patient Characteristics

For patients without contraindications to NSAIDs:

• Use NSAIDs at full anti-inflammatory doses as the initial treatment 1
• Treatment should be initiated within 24 hours of symptom onset for optimal efficacy 1
• NSAIDs are particularly effective but carry risks of gastrointestinal bleeding and cardiovascular toxicity, especially in elderly patients 1

For elderly patients or those with NSAID contraindications:

• Low-dose oral corticosteroids are the preferred first-line option due to their favorable safety profile 2, 1
• Intra-articular aspiration followed by long-acting steroid injection is particularly safe and effective, avoiding systemic medication risks 2, 1
• This approach is especially useful for monoarticular or oligoarticular disease affecting accessible joints 1

Alternative acute treatment:

• Low-dose colchicine (0.5-0.6 mg two to three times daily) is effective with fewer gastrointestinal side effects than traditional high-dose regimens 1
• Avoid high-dose colchicine as it leads to significant gastrointestinal toxicity without additional benefit 1

Polyarticular Attacks

For patients with multiple joint involvement:

• Intramuscular triamcinolone acetonide 60 mg is safe, well-tolerated, and effective when intra-articular injections are impractical 3
• A second injection may be given on Day 1-2 if inadequate response occurs 3
• Major clinical improvement typically occurs by Day 3-4 3

Long-Term Management

Unlike gout, pseudogout has no equivalent to urate-lowering therapy, so long-term management focuses on preventing recurrent attacks and treating underlying conditions 2

Prophylactic Therapy for Frequent Recurrent Attacks

For patients with frequent flares:

• Low-dose colchicine (0.5-0.6 mg once or twice daily) is the preferred prophylactic agent 1
• If colchicine is contraindicated, use low-dose NSAIDs with gastric protection 1
• If both colchicine and NSAIDs are contraindicated, use low-dose corticosteroids (<10 mg/day) 1

Addressing Underlying Conditions

Evaluate and manage contributing factors:

• If the patient is on diuretic therapy, consider stopping the diuretic if possible to reduce attack risk 2
• Address comorbidities including hypertension, hyperlipidemia, and hyperglycemia 2, 1
• These interventions improve overall patient outcomes and may reduce pseudogout frequency 2

Adjuvant and Supportive Measures

Additional interventions to optimize outcomes:

• Apply topical ice packs for pain relief during acute flares 2
• Provide patient education about the condition, including weight loss if obese, dietary modifications, and reduced alcohol consumption 1
• Regular follow-up to assess for recurrent attacks and adjust prophylactic therapy as needed 1

Common Pitfalls to Avoid

Critical considerations for safe and effective treatment:

• Do not use high-dose colchicine regimens; low doses are sufficient and better tolerated 1
• Be cautious with NSAIDs in elderly patients due to increased risk of gastrointestinal and cardiovascular complications 1
• Do not delay treatment; efficacy is optimized when therapy begins within 24 hours of symptom onset 1
• Remember that unlike gout, there is no disease-modifying therapy for pseudogout, so focus remains on acute and prophylactic anti-inflammatory management 2, 4