What is the treatment approach for an older adult with pseudogout (calcium pyrophosphate deposition disease, CPPD) and a history of joint disease?

Treatment of Pseudogout in Older Adults

For older adults with acute pseudogout, intra-articular glucocorticosteroid injection combined with joint aspiration is the optimal first-line treatment for monoarticular or oligoarticular disease, while systemic steroids (prednisone 0.5 mg/kg/day for 5-10 days) are preferred for polyarticular attacks or when joint injection is not feasible, particularly given the high risk of NSAID and colchicine toxicity in this population. 1, 2

Treatment Algorithm by Clinical Presentation

Acute Monoarticular or Oligoarticular Attack

First-line approach:

• Joint aspiration followed by intra-articular injection of long-acting glucocorticosteroids is the treatment of choice 2
• This may be sufficient as monotherapy without requiring systemic medications 2
• Combine with ice application and temporary joint rest 1
• Always exclude septic arthritis before injecting steroids, especially critical in monoarticular presentations 2

Systemic steroid options if intra-articular injection is not feasible:

• Prednisone or prednisolone 0.5 mg/kg/day for 5-10 days, then discontinue 2
• Alternative: full dose for 2-5 days, then taper over 7-10 days 2
• Intramuscular triamcinolone acetonide 60 mg as single dose showed ≥50% clinical improvement in all patients within 14 days 2
• Betamethasone 7 mg IM or methylprednisolone 125 mg IV as single doses showed significant improvement compared to NSAIDs on day 1 2

Acute Polyarticular Attack

Systemic glucocorticosteroids are necessary:

• Oral prednisone/prednisolone 0.5 mg/kg/day for 5-10 days with abrupt discontinuation 2
• Oral methylprednisolone dose pack is appropriate based on current practice patterns 2
• Do not use prolonged courses without a clear tapering plan, as this increases adverse effects without additional benefit 2

Special Considerations for Older Adults

NSAIDs and colchicine should be used with extreme caution or avoided entirely in older patients: 1

• NSAIDs carry high risk of gastrointestinal bleeding, cardiovascular events, and renal impairment 1
• Colchicine at traditional dosing (1 mg loading, then 0.5 mg every 2 hours) causes side effects in 100% of patients 1
• If colchicine is used, employ low-dose regimen: 0.5 mg three to four times daily with or without 1 mg loading dose 1
• Older patients often have chronic renal impairment and comorbidities that increase toxicity risk 1
• Steroids are particularly valuable in older patients with comorbidities who have contraindications to NSAIDs or colchicine 2

Management of Chronic CPPD with Recurrent Attacks

Prophylactic strategies:

• Low-dose colchicine may prevent recurrent attacks 3, 4
• Hydroxychloroquine showed clinical response (NNT=2) in chronic inflammatory arthritis from CPPD 5
• Low-dose weekly methotrexate may be valuable for severe refractory disease 5, 3
• Magnesium supplementation can be used prophylactically, as magnesium deficiency promotes crystal formation 6, 5

Critical Pitfalls to Avoid

• Never inject steroids without first excluding septic arthritis through joint aspiration and synovial fluid analysis 2
• Always assess cardiovascular, renal, and metabolic comorbidities before selecting steroid dose and duration 2
• Avoid NSAIDs in older patients with renal impairment, cardiovascular disease, or gastrointestinal risk factors 1
• Screen for metabolic associations in patients under age 60: primary hyperparathyroidism (3-fold increased risk), hemochromatosis, and hypomagnesemia 5, 3

Key Management Principles

Treatment must be individualized based on:

• Number of joints involved (monoarticular vs polyarticular) 1
• Patient age and comorbidity burden 1
• Renal function and cardiovascular risk 1, 2
• Contraindications to specific drug classes 1

Unlike gout, there is no disease-modifying treatment for CPPD - no agents can prevent CPP crystal formation or enhance their dissolution, so management is restricted to symptomatic control 6, 5

Patient education is essential to allow involvement in decision-making about treatment options and their risks versus benefits 1