What is the treatment for pseudogout?

Treatment for Pseudogout

For acute pseudogout attacks, start with NSAIDs at full anti-inflammatory doses as first-line therapy, or use corticosteroids (intra-articular, intramuscular, or oral) if NSAIDs are contraindicated or in elderly patients with cardiovascular or gastrointestinal risk factors. 1

Acute Attack Management

First-Line Options (Choose Based on Patient Factors)

NSAIDs are the preferred initial treatment when no contraindications exist 1:

• Use full anti-inflammatory doses (e.g., indomethacin 50 mg three times daily or naproxen 500 mg twice daily) 1
• Critical caveat: NSAIDs carry significant risks of gastrointestinal bleeding and cardiovascular toxicity, particularly in elderly patients, so assess risk factors before prescribing 1
• Start within 24 hours of symptom onset for optimal efficacy 1

Corticosteroids should be your first choice in patients with NSAID contraindications and have a favorable safety profile 1:

• Intra-articular injection: Most effective for monoarticular attacks in accessible joints—aspirate the joint first, then inject long-acting corticosteroids 1
• Intramuscular route: Triamcinolone acetonide 60 mg IM produces major clinical improvement by days 3-4 in most patients and is particularly useful for polyarticular attacks where intra-articular injection is impractical 2
• Oral corticosteroids: Use when other routes are not feasible; doses <10 mg/day for maintenance 1

Colchicine is an effective alternative with better tolerability at low doses 1:

• Use 0.5-0.6 mg two to three times daily for acute attacks 1
• Avoid high-dose regimens: They cause significant gastrointestinal side effects without added benefit; low doses are sufficient and better tolerated 1

Long-Term Prophylactic Management

For patients with frequent recurrent attacks, prescribe prophylactic low-dose colchicine 1:

• Dose: 0.5-0.6 mg once or twice daily 1
• Alternative: Low-dose NSAIDs with gastric protection (proton pump inhibitor) if colchicine is not tolerated 1
• Second alternative: Low-dose corticosteroids (<10 mg/day prednisone equivalent) if both colchicine and NSAIDs are contraindicated 1

Essential Adjunctive Measures

Address modifiable risk factors and comorbidities 1:

• Weight loss if obese 1
• Reduce alcohol consumption 1
• Manage hyperlipidemia, hypertension, and hyperglycemia, which are commonly associated with pseudogout 1

Treatment Algorithm

1. Monoarticular attack + accessible joint → Aspirate and inject intra-articular corticosteroid 1
2. Monoarticular attack + no contraindications to NSAIDs → Full-dose NSAID 1
3. Elderly patient or NSAID contraindications → Intramuscular triamcinolone 60 mg 1, 2
4. Polyarticular attack → Intramuscular or oral corticosteroids 1, 2
5. Frequent recurrent attacks (≥2-3 per year) → Start prophylactic low-dose colchicine 1

Critical Pitfalls to Avoid

• Do not delay treatment: Efficacy decreases significantly if treatment is not initiated within 24 hours of symptom onset 1
• Do not use high-dose colchicine: The traditional high-dose regimen causes severe gastrointestinal toxicity without improved efficacy 1
• Do not prescribe NSAIDs without assessing cardiovascular and gastrointestinal risk: Elderly patients are particularly vulnerable to NSAID complications 1, 3
• Do not forget joint aspiration: Always aspirate when performing intra-articular injection to confirm diagnosis and decompress the joint 1