Treatment for Pseudogout (Calcium Pyrophosphate Deposition Disease)
Acute Attack Management
For acute pseudogout attacks, joint aspiration combined with intra-articular glucocorticosteroid injection is the preferred first-line treatment for monoarticular or oligoarticular involvement, providing the most rapid symptom relief. 1
Initial Measures
- Apply ice or cool packs to the affected joint(s) and implement temporary rest to reduce inflammation and pain 1
- Perform joint aspiration both for diagnostic confirmation and therapeutic benefit, particularly when combined with corticosteroid injection 1
Pharmacologic Options (in order of preference)
First-line systemic therapy:
- Oral NSAIDs at doses similar to those used for acute gout attacks are effective first-line agents when intra-articular injection is not feasible 1
- Use standard anti-inflammatory dosing (e.g., indomethacin 50 mg three times daily or naproxen 500 mg twice daily) 2
Second-line therapy:
- Low-dose colchicine: 0.5 mg up to three to four times daily (with or without a 1 mg loading dose) minimizes gastrointestinal side effects while maintaining efficacy 1
- This lower-dose regimen is critical—avoid traditional high-dose colchicine regimens that cause severe gastrointestinal toxicity 1
Third-line therapy:
- Oral corticosteroids (e.g., prednisone 30-40 mg daily with taper) for patients with contraindications to both NSAIDs and colchicine 1
Rescue therapy:
- IL-1 blockers may be considered for patients with contraindications to all standard therapies, though evidence is extrapolated from gout management 1
Critical Contraindications to Avoid
- Do not use colchicine or NSAIDs in patients with severe renal impairment 1
- Do not prescribe colchicine to patients taking strong P-glycoprotein or CYP3A4 inhibitors (cyclosporin, clarithromycin) due to risk of severe toxicity 1
- Exercise particular caution with NSAIDs in elderly patients given high risks of gastrointestinal, renal, and cardiovascular complications 1
Prophylactic Treatment for Recurrent Attacks
For patients experiencing frequent recurrent pseudogout attacks, prophylactic low-dose colchicine (0.5-1 mg daily) is recommended. 1
- Low-dose NSAIDs can serve as an alternative prophylactic option in patients who tolerate them well 1
- Fully explain the rationale for prophylaxis to patients, emphasizing prevention of recurrent attacks 1
- Unlike gout, there is no urate-lowering equivalent for pseudogout since the disease involves calcium pyrophosphate crystals rather than uric acid 1
Chronic CPPD Management
Treatment must be individualized based on clinical presentation, severity, and comorbidities. 1
For CPPD with Osteoarthritis:
- Implement standard osteoarthritis management including physical therapy and appropriate exercise programs 1
- Recommend weight loss for overweight or obese patients 1
- Use analgesics as needed for pain control 1
Address Underlying Metabolic Disorders:
Screen for and treat secondary causes including hyperparathyroidism, hemochromatosis, and hypomagnesemia—treating the underlying condition is essential. 1
Patient Education Essentials
Educate patients on:
- Disease pathophysiology and the nature of calcium pyrophosphate crystal deposition 1
- Available treatment options and their limitations 1
- Associated comorbidities and cardiovascular risk factors that require screening 1
- Lifestyle modifications including weight loss, regular exercise, and dietary changes 1
Key Clinical Pitfalls
- Avoid traditional high-dose colchicine regimens that cause severe gastrointestinal toxicity; use lower doses 1
- Do not use long-term NSAIDs indiscriminately in elderly patients without considering gastrointestinal, renal, and cardiovascular risks 1
- Do not miss screening for metabolic disorders (hyperparathyroidism, hemochromatosis, hypomagnesemia) that may be driving CPPD 1
- Remember that pseudogout can occur without radiographic chondrocalcinosis—diagnosis relies on crystal identification from joint aspiration 3