Steroid Dosing for Acute CPPD Arthritis
For acute CPPD arthritis requiring systemic steroids, use oral prednisone or prednisolone at 0.5 mg/kg/day for 5-10 days followed by discontinuation, or alternatively give full dose for 2-5 days followed by a 7-10 day taper. 1
Intra-articular Steroids (First-Line for Monoarticular/Oligoarticular Disease)
- Intra-articular injection of long-acting glucocorticosteroids is the optimal first-line treatment for monoarticular or oligoarticular acute CPPD arthritis, combined with joint aspiration, ice application, and temporary rest 1, 2
- For many patients, intra-articular injection alone may be sufficient without requiring systemic therapy 1
- Specific doses studied include triamcinolone acetonide 60 mg intramuscularly, which showed at least 50% clinical improvement in all patients within 14 days 1
- One small trial used 7 mg betamethasone intramuscularly or 125 mg methylprednisolone intravenously as single doses, both showing significant improvement compared to NSAIDs on day 1 1
Oral Systemic Steroids (When Intra-articular Not Feasible)
When intra-articular injection is impractical due to polyarticular involvement, patient preference, or provider scope of practice:
- Prednisone or prednisolone at 0.5 mg/kg/day (minimum dose) for 5-10 days, then discontinue 1
- Alternative regimen: Full dose for 2-5 days, then taper over 7-10 days before discontinuation 1
- Oral methylprednisolone dose pack is an appropriate option based on current clinical practice patterns 1
- The EULAR guidelines recommend "a short tapering course of oral glucocorticosteroids" as effective for acute CPPD not amenable to intra-articular injection 1
Parenteral Steroids (Alternative Route)
- Intramuscular triamcinolone acetonide 60 mg as a single dose, followed by oral prednisone/prednisolone, is an appropriate alternative regimen 1
- Intramuscular triamcinolone acetonide as monotherapy did not reach consensus in gout guidelines, but has shown efficacy in CPPD case series 1
- Parenteral ACTH 40-80 units (intravenous, intramuscular, or subcutaneous) has been used successfully in retrospective studies of acute crystal arthritis 1
Key Clinical Context
The evidence for steroid dosing in CPPD is largely extrapolated from gout studies, as there are no randomized controlled trials specifically examining steroid doses in acute CPPD arthritis 1. The EULAR recommendations carry a level of evidence of IIb-III for systemic steroids in CPPD 1.
Steroids are particularly valuable in older patients with comorbidities who have contraindications to NSAIDs (renal impairment, cardiovascular disease, GI bleeding risk) or colchicine 1. Since CPPD predominantly affects older patients, steroids often provide the best benefit-risk ratio 3.
Critical Pitfalls to Avoid
- Do not use prolonged courses of steroids without a clear tapering plan, as this increases adverse effects without additional benefit 1
- Always exclude septic arthritis before injecting steroids into a joint, particularly in monoarticular presentations 1
- Assess cardiovascular, renal, and metabolic comorbidities before selecting steroid dose and duration, especially in elderly patients 1
- Consider bone protection (calcium 800-1000 mg/day and vitamin D 400-800 units/day) if using repeated courses or chronic low-dose steroids 4, 5