What is the treatment for pseudogout?

Treatment for Pseudogout

For acute pseudogout attacks, NSAIDs at full anti-inflammatory doses, low-dose colchicine (0.5-0.6 mg two to three times daily), or corticosteroids are all effective first-line options, with corticosteroids being particularly advantageous in elderly patients or those with contraindications to NSAIDs. 1

Acute Attack Management

First-Line Monotherapy Options

• NSAIDs at full anti-inflammatory doses are recommended as effective first-line agents when no contraindications exist 1

  • Particularly effective when initiated within 24 hours of symptom onset 1
  • Carry risks of gastrointestinal bleeding and cardiovascular toxicity, especially in elderly patients 1

• Low-dose colchicine (0.5-0.6 mg two to three times daily) is effective with fewer gastrointestinal side effects than traditional high-dose regimens 1

  • For acute treatment: 1.2 mg (two tablets) at first sign of flare, followed by 0.6 mg one hour later 2
  • Maximum dose for acute treatment is 1.8 mg over one hour 2
  • High doses cause significant gastrointestinal toxicity; low doses are generally sufficient and better tolerated 1

• Corticosteroids should be considered as first-line therapy due to their favorable safety profile, particularly in patients with contraindications to NSAIDs 1

  • Oral, intramuscular, or intravenous routes are all effective 1
  • Intramuscular triamcinolone acetonide 60 mg produces major clinical improvement by Day 3-4 in most patients 3
  • Intravenous/intramuscular methylprednisolone 0.5-2.0 mg/kg can be used for patients unable to take oral medication 1

Intra-articular Therapy

• Intra-articular aspiration and injection of long-acting steroids is effective and safe for acute pseudogout affecting accessible joints 1
  • Particularly useful for monoarticular disease 3
  • Should be considered when systemic therapy is contraindicated 1

Combination Therapy for Severe Disease

• For severe pain or polyarticular involvement, use two agents simultaneously: 1
  • Colchicine plus NSAIDs
  • Oral corticosteroids plus colchicine
  • Intra-articular steroids with any other modality

Critical Timing Considerations

• Treatment must be initiated within 24 hours of symptom onset for optimal efficacy 1
• Delayed treatment beyond 24 hours significantly reduces effectiveness 1
• Patient education enabling self-initiation of treatment at first symptom onset is crucial 1

Monitoring Treatment Response

• Inadequate response is defined as: 1

  • Less than 20% pain improvement within 24 hours, OR
  • Less than 50% improvement after 24 hours

• If inadequate response occurs: 1

  • Switch to alternative monotherapy, OR
  • Add a second agent
  • Consider alternative diagnoses such as septic arthritis

Long-Term Prophylactic Management

For Patients with Frequent Recurrent Attacks

• Low-dose colchicine (0.5-0.6 mg once or twice daily) is recommended for prophylaxis 1

  • Maximum prophylactic dose is 1.2 mg/day 2
  • Can be administered as single or divided doses 2

• Low-dose NSAIDs with gastric protection if colchicine is contraindicated 1

• Low-dose corticosteroids (<10 mg/day) if both colchicine and NSAIDs are contraindicated 1

Important Distinction from Gout

Unlike gout, there is no standard regimen for long-term chronic therapies or urate-lowering therapy for pseudogout 4. The provided evidence about allopurinol and febuxostat applies to gout, not pseudogout 5.

Special Populations and Dose Adjustments

Renal Impairment (for colchicine)

• Mild to moderate impairment (CrCl 30-80 mL/min): No dose adjustment required, but monitor closely 2
• Severe impairment (CrCl <30 mL/min): Start with 0.3 mg/day for prophylaxis; for acute treatment, repeat courses no more than once every two weeks 2
• Dialysis patients: 0.3 mg twice weekly for prophylaxis; single 0.6 mg dose for acute treatment, repeated no more than once every two weeks 2

Hepatic Impairment (for colchicine)

• Mild to moderate impairment: No dose adjustment required, but monitor closely 2
• Severe impairment: Consider dose reduction; repeat acute treatment courses no more than once every two weeks 2

Drug Interactions with Colchicine

• Strong CYP3A4 inhibitors (clarithromycin, ketoconazole, ritonavir, etc.) are contraindicated with colchicine due to risk of fatal toxicity 2
• If coadministration is unavoidable, reduce colchicine dose significantly 2

Patient Education and Lifestyle Modifications

• Weight loss if obese should be recommended as a core aspect of management 1
• Address associated comorbidities including hyperlipidemia, hypertension, and hyperglycemia 1
• Educate patients about early symptom recognition to enable prompt self-treatment 1

Common Pitfalls to Avoid

• Do not use high-dose colchicine regimens as they cause significant gastrointestinal toxicity without improved efficacy 1
• Do not delay treatment beyond 24 hours as this significantly reduces effectiveness 1
• Do not confuse pseudogout with septic arthritis when treatment response is inadequate 1
• Do not prescribe urate-lowering therapy (allopurinol, febuxostat) for pseudogout as these are only effective for gout 4