How to manage CPPD (Calcium Pyrophosphate Deposition Disease) in an elderly patient?

Management of CPPD in Elderly Patients

For elderly patients with CPPD, prioritize joint aspiration with intra-articular corticosteroid injection for acute attacks, and use low-dose colchicine (0.5 mg once or twice daily) for prophylaxis, while avoiding traditional high-dose NSAIDs due to the high risk of gastrointestinal bleeding, cardiovascular events, and renal impairment in this population. 1, 2

Acute CPP Crystal Arthritis Management

First-Line Approach

• Apply ice packs, enforce temporary joint rest, and perform joint aspiration with intra-articular long-acting glucocorticosteroid injection - this combination is often sufficient as monotherapy for monoarticular or oligoarticular attacks 1, 2
• Joint aspiration serves dual purposes: confirms CPP crystal diagnosis and provides immediate therapeutic benefit when combined with corticosteroid injection 1, 2

Systemic Treatment Options (when intra-articular injection not feasible)

• Low-dose colchicine regimen: 0.5 mg three to four times daily (with or without 1 mg loading dose) - avoid traditional high-dose regimens (1 mg loading followed by 0.5 mg every 2 hours) which cause 100% incidence of side effects 1
• Oral NSAIDs with mandatory gastroprotection - use cautiously in elderly due to high risk of gastrointestinal bleeding, cardiovascular events, and renal impairment 1
• Short tapering course of oral prednisone or parenteral corticosteroids - reserve for patients with contraindications to NSAIDs or colchicine, or when intra-articular injection is not possible 2, 3

Critical Safety Considerations for Elderly

• NSAIDs and colchicine use is severely limited by toxicity in older patients who frequently have chronic renal impairment and multiple comorbidities 1
• Never use intravenous colchicine - carries high risk of serious toxicity and fatality 1, 2
• Prednisone may provide the best benefit-risk ratio specifically in elderly patients with acute attacks 3

Prophylaxis Against Recurrent Attacks

• Low-dose colchicine 0.5-1.0 mg daily is the preferred prophylactic agent 1, 2, 4
• Alternative: Low-dose oral NSAID with gastroprotection, though less desirable in elderly due to cumulative toxicity risk 1, 4
• Prophylaxis is indicated for patients experiencing frequent recurrent acute attacks 1, 2

Chronic CPP Crystal Inflammatory Arthritis

Treatment Hierarchy

1. First-line: Oral NSAIDs (with gastroprotection) and/or low-dose colchicine (0.5-1.0 mg daily) 1, 2, 4

   • Low-dose colchicine (0.5 mg twice daily) demonstrated NNT of 2 for >30% pain reduction at 4 months in controlled trials 4

2. Second-line: Hydroxychloroquine - demonstrated NNT of 2 for clinical response (>30% reduction in swollen/tender joint count) in 6-month RCT 1, 4

3. Third-line: Methotrexate (5-10 mg/week) - for refractory cases resistant to first-line treatments, with excellent clinical response in uncontrolled trials 4, 5

4. Fourth-line: Low-dose oral corticosteroids - when other treatments fail, though based primarily on expert opinion 1, 4

5. Refractory cases: Consider tocilizumab or anakinra (IL-6 or IL-1 inhibitors) for patients failing conventional therapy 6, 3

Management of CPPD with Osteoarthritis

• Apply identical management objectives and treatment options as for osteoarthritis without CPPD 1
• Include education, physical therapy, and joint protection strategies 4
• Avoid intra-articular high molecular weight hyaluronan - may induce acute attacks 4

Screening and Treatment of Associated Metabolic Conditions

Screen for and treat the following conditions if detected: 1, 2

• Hyperparathyroidism (OR 3.03 for CPPD association)
• Hemochromatosis
• Hypomagnesemia
• Hypophosphatasia

Treatment of these comorbidities is mandatory, though whether it affects CPPD arthritis outcomes remains unclear 1

Asymptomatic Chondrocalcinosis

• No treatment required - asymptomatic radiographic chondrocalcinosis is an age-related finding that does not warrant intervention 1, 2
• Currently no treatment exists to modify CPP crystal formation or enhance dissolution 1

Special Considerations for Cervical Spine CPPD (Crowned Dens Syndrome)

• Presents with acute posterior neck pain, fever, markedly restricted neck rotation, and elevated CRP 7
• CT demonstrates linear calcific deposits in transverse ligament of atlas 7
• Treat with NSAIDs or combination of NSAIDs plus prednisolone - symptoms resolve within 1-3 weeks 7

Common Pitfalls to Avoid

• Failing to start treatment early significantly reduces effectiveness 2
• Using traditional high-dose colchicine regimens guarantees marked side effects 1, 2
• Prescribing NSAIDs without assessing renal function, cardiovascular risk, and gastrointestinal bleeding risk in elderly patients 1
• Overlooking the need for gastroprotection when using NSAIDs long-term 1
• Missing underlying metabolic disorders that require specific treatment 1, 2