What is the management for Calcium Pyrophosphate Deposition (CPPD) disease or pseudogout?

Management of Calcium Pyrophosphate Deposition (CPPD) Disease/Pseudogout

For acute pseudogout attacks, joint aspiration with intra-articular corticosteroid injection is the most effective first-line treatment, supplemented by cool packs and temporary rest; for patients requiring systemic therapy, use NSAIDs with gastroprotection or low-dose colchicine (0.5-1.0 mg daily). 1, 2

Treatment Algorithm Based on Clinical Presentation

Asymptomatic Chondrocalcinosis

• No treatment is required - this is typically an age-related finding in normal populations and does not cause morbidity 1, 2

Acute CPP Crystal Arthritis (Pseudogout Attack)

First-Line Approach:

• Joint aspiration with intra-articular long-acting glucocorticosteroid injection is highly effective and safe for monoarticular or oligoarticular attacks 1, 2
• Apply ice or cool packs to the affected joint 1, 2
• Implement temporary rest of the affected joint 1, 2

Systemic Treatment When Intra-articular Injection Not Feasible:

• Oral NSAIDs with gastroprotective agents (particularly critical in elderly patients who predominate in CPPD) 1, 2
• Low-dose oral colchicine 0.5-1.0 mg daily 1, 2

For Patients with Contraindications to NSAIDs or Colchicine:

• Short tapering course of oral corticosteroids 1, 2
• Parenteral corticosteroids 1, 2
• ACTH injection 1, 2

Refractory Acute Cases:

• Anakinra (IL-1 receptor antagonist) can be administered for acute flares unresponsive to standard treatments 3, 4

Prophylaxis Against Recurrent Attacks

• Low-dose oral colchicine (0.5 mg twice daily) has demonstrated efficacy with an NNT of 2 for pain reduction >30% at 4 months 5, 2
• Low-dose oral NSAIDs with gastroprotection as an alternative or adjunct 1, 2

Chronic CPP Crystal Inflammatory Arthritis

First-Line Treatments:

• Oral NSAIDs with gastroprotective agents 1, 5, 2
• Low-dose colchicine (0.5-1.0 mg daily) 1, 5, 2

Second-Line Treatments for Inadequate Response:

• Methotrexate (5-10 mg/week) showed excellent clinical response in all treated patients with significant decrease in pain intensity and joint swelling in uncontrolled trials 5
• Hydroxychloroquine demonstrated efficacy with an NNT of 2 for clinical response (>30% reduction in swollen/tender joint count) in a 6-month double-blind RCT 5, 4
• Low-dose oral corticosteroids 1, 5, 2

Refractory Chronic Cases:

• Tocilizumab can be used when other treatments fail 3, 4

Erosive CPPD Disease

This severe phenotype requires more aggressive management:

• NSAIDs as initial therapy, always with gastroprotective agents 5
• Low-dose colchicine (0.5 mg twice daily) 5
• Joint aspiration with intra-articular corticosteroid injection for significantly inflamed joints 5
• Methotrexate (5-10 mg/week) for erosive CPPD resistant to first-line treatments 5
• Hydroxychloroquine as an alternative second-line agent 5

Critical Management Principles

Unlike gout, there is currently no disease-modifying therapy to eliminate CPP crystals or prevent their formation - all treatment is symptomatic control rather than disease modification 1, 6, 7

Address underlying metabolic conditions:

• Screen for and treat hyperparathyroidism, hemochromatosis, and hypomagnesemia, as these predispose to CPPD development 5, 2, 6
• Magnesium deficiency promotes CPP crystal formation; medications like furosemide can precipitate CPPD through magnesium depletion 6

Tailor treatment to patient age and comorbidities:

• CPPD predominantly affects older patients who often have contraindications to certain medications 1, 5, 2
• Carefully weigh benefit versus risk when prescribing NSAIDs in elderly patients 1

Common Pitfalls to Avoid

• Never use intravenous colchicine due to high risk of serious toxicity 2
• Avoid traditional high-dose colchicine regimens which lead to marked gastrointestinal side effects 2
• Do not use intra-articular high molecular weight hyaluronan as it may induce acute attacks in CPPD patients 5
• Failing to start treatment early significantly reduces effectiveness 2
• Monitor for side effects of long-term treatments, particularly with NSAIDs (gastrointestinal bleeding, cardiovascular events, renal dysfunction), colchicine (diarrhea, cytopenias), and methotrexate (hepatotoxicity, cytopenias) 5, 2

Non-Pharmacological Management

• Patient education about disease characteristics and treatment options 1
• Apply standard osteoarthritis management principles including physical therapy and joint protection strategies 5
• These measures should complement, not replace, pharmacological treatment 1