What is the recommended treatment for a patient with CPPD (Calcium Pyrophosphate Dihydrate) mineralization and arthrosis in the joints?

Treatment for CPPD Mineralization with Arthrosis

For this patient with asymptomatic CPPD mineralization and mild arthrosis, no specific treatment for the CPPD is required, and management should focus on the osteoarthritis using standard evidence-based OA therapies. 1

Key Management Principle

• Currently, no treatment modifies CPP crystal formation or dissolution, and no treatment is required for asymptomatic chondrocalcinosis. 1
• The EULAR guidelines explicitly state that asymptomatic CPPD (chondrocalcinosis visible on imaging without inflammatory symptoms) does not warrant pharmacological intervention. 1

Management Approach Based on Clinical Presentation

For Asymptomatic CPPD (This Patient's Presentation)

• No pharmacological treatment is indicated for the CPPD mineralization itself, as the patient shows no evidence of acute or chronic inflammatory arthritis. 1
• The radiographic findings show CPPD deposition but no erosions, suggesting this is asymptomatic chondrocalcinosis rather than active inflammatory disease. 1

For the Concurrent Arthrosis

• Management should follow standard osteoarthritis treatment guidelines, as the therapeutic approach for OA with CPPD is identical to OA without CPPD. 1
• Treatment options include both non-pharmacological (physical therapy, weight management, assistive devices) and pharmacological modalities (acetaminophen, NSAIDs with gastroprotection) tailored to symptom severity. 1

Screening for Metabolic Conditions

Screen for associated metabolic disorders that predispose to CPPD, as their treatment is indicated regardless of CPPD symptoms:

• Primary hyperparathyroidism (patients with CPPD are 3 times more likely to have this condition, OR=3.03). 1
• Hemochromatosis and hypomagnesemia should also be evaluated. 1, 2
• If detected, these metabolic conditions should be treated according to their respective guidelines. 1

When to Initiate CPPD-Specific Treatment

Only treat if the patient develops symptomatic disease:

For Acute CPP Crystal Arthritis (if it develops)

• First-line: Joint aspiration with intra-articular glucocorticoid injection, ice application, and temporary rest (SOR 95%). 1
• Systemic options: Low-dose colchicine (0.5 mg up to 3-4 times daily) or NSAIDs with gastroprotection, though use is limited by comorbidities in older patients. 1
• Alternative: Short tapering course of oral glucocorticoids or parenteral glucocorticoids for polyarticular attacks. 1

For Chronic CPP Crystal Inflammatory Arthritis (if it develops)

• Pharmacological hierarchy: NSAIDs with gastroprotection and/or colchicine (0.5-1.0 mg daily) as first-line, followed by low-dose corticosteroids, methotrexate (5-10 mg/week), or hydroxychloroquine for refractory cases. 1
• Methotrexate showed excellent clinical response in refractory chronic CPPD with significant decreases in pain, joint counts, and attack frequency (p<0.0001). 1
• Hydroxychloroquine demonstrated NNT of 2 for clinical response in chronic inflammatory arthritis with CPPD. 1

Critical Pitfalls to Avoid

• Do not use intra-articular hyaluronan in joints with CPPD, as it may precipitate acute attacks. 1
• Avoid treating asymptomatic CPPD with anti-inflammatory medications, as there is no evidence of benefit and potential for harm, especially in older patients. 1
• Do not assume all joint symptoms are from OA alone—if acute inflammatory symptoms develop (sudden severe pain, swelling, erythema), consider acute CPP crystal arthritis and aspirate the joint for crystal analysis. 1, 3

Monitoring Strategy

• Monitor for development of acute flares (sudden onset severe joint pain, swelling, warmth) which would warrant CPPD-specific treatment. 3
• Reassess if symptoms worsen beyond typical OA progression, as this may indicate transition to chronic CPP crystal inflammatory arthritis. 1
• Follow standard OA monitoring for progression of arthrosis and functional status. 1