What is the recommended treatment for pseudogout?

Treatment of Pseudogout (Calcium Pyrophosphate Deposition Disease)

For acute pseudogout attacks, joint aspiration with intra-articular corticosteroid injection is the preferred first-line treatment, particularly in elderly patients or those with monoarticular/oligoarticular involvement, as it provides rapid symptom relief while avoiding systemic medication risks. 1, 2

Acute Attack Management

First-Line Options (Choose Based on Clinical Scenario)

Intra-articular corticosteroids:

• Joint aspiration combined with long-acting glucocorticosteroid injection is most effective for monoarticular or oligoarticular attacks 2
• Particularly safe in elderly patients who commonly have contraindications to NSAIDs 1
• Provides rapid symptom relief without systemic medication risks 1

Oral NSAIDs:

• Effective first-line agents when intra-articular injection is not feasible 2
• Dose similarly to acute gout attacks 2
• Critical caveat: Long-term use carries significant gastrointestinal, renal, and cardiovascular risks, especially in elderly patients who are the typical pseudogout demographic 2

Low-dose oral corticosteroids:

• Safe for short-term use and should be considered first-line in elderly patients with NSAID contraindications 1
• Prednisone is effective for patients who cannot tolerate NSAIDs or colchicine 2

Colchicine:

• Lower doses (0.5 mg up to three to four times daily, with or without 1 mg loading dose) minimize side effects while maintaining efficacy 2
• Critical pitfall: Avoid traditional high-dose regimens that cause severe gastrointestinal toxicity 2
• Contraindicated in severe renal impairment 2
• Must not be given with strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin) 2

Alternative Therapy for Refractory Cases

Intramuscular corticosteroids:

• Triamcinolone acetonide 60 mg IM is safe, well-tolerated, and effective 3
• Reasonable alternative when NSAIDs are contraindicated or for polyarticular attacks where intra-articular injections are impractical 3
• Major clinical improvement typically occurs by Day 3-4 3
• May require second injection on Day 1-2 in approximately 40% of patients 3

Adjuvant Measures

• Apply ice or cool packs to affected joints 2
• Temporary rest of affected joint(s) 2

Prophylactic Treatment for Recurrent Attacks

For patients with frequent recurrent pseudogout attacks:

• Low-dose colchicine (0.5-1 mg daily) may be considered 1, 2
• Lower-dose NSAIDs can be used in patients who tolerate them well with history of recurrent attacks 2
• Key distinction from gout: There is no equivalent to urate-lowering therapy for pseudogout, as the disease involves calcium pyrophosphate crystals rather than uric acid 1, 2

Long-Term Management of Chronic CPPD

No standard long-term regimen exists for pseudogout 1, 4

Management focuses on:

• Treating underlying metabolic disorders (hyperparathyroidism, hemochromatosis, hypomagnesemia) when present 2
• For CPPD associated with osteoarthritis: employ standard OA management including physical therapy and appropriate exercise programs 2
• Weight loss if overweight or obese 2
• Analgesics for pain control as needed 2

Critical Management Considerations

Diuretic management:

• If patient is on diuretic therapy, consider stopping the diuretic if possible to reduce risk of pseudogout attacks 1

Address comorbidities:

• Hypertension, hyperlipidemia, and hyperglycemia should be managed as part of comprehensive care 1

Patient education:

• Fully inform patients about disease pathophysiology, available treatments, associated comorbidities, and management principles 2
• Include lifestyle advice: weight loss if appropriate, regular exercise, and dietary modifications 2