Treatment of Pseudogout
For acute pseudogout attacks, initiate NSAIDs at full anti-inflammatory doses, low-dose colchicine (0.5-0.6 mg two to three times daily), or corticosteroids (oral, intra-articular, or intramuscular) within 24 hours of symptom onset, with choice based on contraindications and joint involvement. 1
Acute Attack Management
First-Line Monotherapy Options
NSAIDs are recommended as first-line therapy when no contraindications exist 1. Use full anti-inflammatory doses and continue until complete symptom resolution 1. Avoid in patients with heart failure, peptic ulcer disease, significant renal disease, or cardiovascular risk factors 2.
Low-dose colchicine (0.5-0.6 mg two to three times daily) is highly effective with fewer gastrointestinal side effects than traditional high-dose regimens 1. For acute treatment, the FDA-approved dosing is 1.2 mg (two tablets) at first sign of flare followed by 0.6 mg one hour later, with maximum dose of 1.8 mg over one hour 3. Higher doses provide no additional benefit but significantly increase gastrointestinal toxicity 1.
Corticosteroids should be considered first-line therapy due to their favorable safety profile, particularly in patients with contraindications to NSAIDs 1. Options include:
- Oral prednisone 0.5 mg/kg per day for 5-10 days 2
- Intra-articular injection of long-acting steroids for accessible joints (highly effective for single joint involvement) 1, 2
- Intramuscular triamcinolone acetonide 60 mg (effective within 1-4 days, safe alternative when NSAIDs contraindicated) 4
- Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg for NPO patients 5
Combination Therapy
For severe pain or polyarticular involvement (≥4 joints), use combination therapy with two agents simultaneously 5, 1. Appropriate combinations include:
- Colchicine plus NSAIDs 5
- Oral corticosteroids plus colchicine 5
- Intra-articular steroids with any other modality 5
Avoid combining NSAIDs with systemic corticosteroids due to synergistic gastrointestinal toxicity 5.
Special Populations
Renal impairment: For severe renal impairment (CrCl <30 mL/min), reduce colchicine to 0.3 mg/day with close monitoring 3. For dialysis patients, use 0.3 mg twice weekly for prophylaxis or single 0.6 mg dose for acute attacks (not repeated more than once every two weeks) 3.
Hepatic impairment: In severe hepatic disease, monitor closely and consider dose reduction 3. For acute treatment, do not repeat colchicine courses more than once every two weeks 3.
Drug interactions: When strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, etc.) are used, reduce colchicine dose significantly or avoid combination entirely 3.
Long-Term Prophylaxis
For patients with frequent recurrent attacks, initiate prophylactic therapy with 1:
- Low-dose colchicine 0.5-0.6 mg once or twice daily 1
- Low-dose NSAIDs with gastric protection if indicated 1
- Low-dose corticosteroids (<10 mg/day prednisone) if colchicine and NSAIDs are contraindicated 1
Non-Pharmacologic Measures
Address modifiable risk factors including 1:
- Weight loss if obese 1
- Dietary modifications 1
- Reduced alcohol consumption 1
- Management of associated comorbidities (hyperlipidemia, hypertension, hyperglycemia) 1
Critical Pitfalls to Avoid
Delayed treatment beyond 24 hours significantly reduces effectiveness 1. Provide patient education enabling self-initiation of treatment at first symptom onset 5.
High-dose colchicine causes severe gastrointestinal toxicity without improved efficacy 1. The traditional high-dose regimen is obsolete.
Inadequate response is defined as <20% pain improvement within 24 hours or <50% improvement after 24 hours 5. When this occurs, switch to alternative monotherapy or add a second agent 5. Consider alternative diagnoses including septic arthritis 5.
Polyarticular attacks require more aggressive therapy—do not use monotherapy for severe or multi-joint involvement 5, 1.