What is the best treatment approach for an elderly patient presenting with pseudo gout (calcium pyrophosphate deposition disease) in the knee?

Pseudogout (CPPD) in the Knee: Presentation and Treatment

Clinical Presentation

Pseudogout in the knee typically presents as acute monoarticular arthritis with severe pain, swelling, warmth, and erythema, often mimicking septic arthritis or gout. 1

Key distinguishing features in elderly patients include:

• More frequent polyarticular involvement compared to classic gout, with knees being the most commonly affected large joint 1, 2
• Systemic upset may accompany acute attacks, particularly in older adults 3
• Less dramatic presentation than gout, with a more indolent course in some cases 1
• Concurrent osteoarthritis is common, as CPPD frequently coexists with degenerative joint disease 1

Critical pitfall: Always exclude septic arthritis before initiating treatment, especially before any intra-articular injection—this is non-negotiable in monoarticular presentations. 4

Treatment Algorithm for Acute CPPD Arthritis in the Knee

First-Line Treatment: Intra-articular Corticosteroids

For acute pseudogout in the knee, intra-articular injection of long-acting glucocorticosteroids combined with joint aspiration is the optimal first-line treatment. 1, 4

• Perform joint aspiration first to confirm CPP crystals and exclude infection 1
• Inject triamcinolone acetonide or equivalent long-acting corticosteroid preparation 4
• Combine with ice application and temporary rest of the affected joint 1
• This approach may be sufficient as monotherapy without requiring systemic medications in many patients 4

Second-Line: Systemic Corticosteroids

When intra-articular injection is not feasible or for polyarticular disease, use oral corticosteroids as the preferred systemic therapy in elderly patients. 4, 5

Specific dosing regimens:

• Prednisone/prednisolone 0.5 mg/kg/day for 5-10 days, then discontinue 4
• Alternative: Full dose for 2-5 days, then taper over 7-10 days 4
• Methylprednisolone dose pack is an acceptable alternative 4
• For severe cases: Intramuscular triamcinolone acetonide 60 mg as single dose followed by oral prednisone 4

Critical consideration: Corticosteroids are particularly valuable in elderly patients with renal impairment, cardiovascular disease, or peptic ulcer disease who cannot tolerate NSAIDs or colchicine. 4, 5

Third-Line Options (Use with Extreme Caution in Elderly)

NSAIDs should be avoided in most elderly patients due to high risk of gastrointestinal bleeding, renal toxicity, and cardiovascular complications. 1, 6, 5

If NSAIDs must be used:

• Choose short half-life agents (diclofenac, ketoprofen) 6
• Always combine with proton pump inhibitors for gastroprotection 1
• Absolutely contraindicated in patients with peptic ulcer disease, renal failure, uncontrolled hypertension, or heart failure 6

Colchicine is poorly tolerated and best avoided in elderly patients with acute CPPD. 1, 6

If colchicine is considered:

• Use low-dose regimen only: 0.5 mg three to four times daily (not the traditional high-dose regimen) 1
• Contraindicated in renal impairment, which is common in elderly patients 5, 7
• Traditional dosing causes 100% incidence of side effects 1

Management of Chronic CPPD with Concurrent Osteoarthritis

Treat chronic CPPD with concurrent OA following evidence-based OA management guidelines, with special attention to the inflammatory component. 1

• Low-dose colchicine (0.5 mg twice daily) showed NNT of 2 for >30% pain reduction in chronic CPPD with persistent inflammation 1
• Hydroxychloroquine demonstrated NNT of 2 for clinical response in chronic inflammatory arthritis with CPPD 1
• Low-dose methotrexate (5-10 mg/week) may be valuable for severe refractory CPPD, though evidence is limited to uncontrolled trials 1
• Avoid high molecular weight hyaluronan intra-articular injections as they may induce acute attacks 1

Key Clinical Pitfalls to Avoid

• Never use prolonged corticosteroid courses without a clear tapering plan—this increases adverse effects without additional benefit 4
• Do not initiate treatment without synovial fluid analysis when feasible, as distinguishing CPPD from gout and septic arthritis is critical 1
• Assess cardiovascular, renal, and metabolic comorbidities before selecting any treatment, especially in elderly patients 4
• Recognize that asymptomatic chondrocalcinosis requires no treatment—only symptomatic CPPD warrants intervention 1

Important Distinction

Calcium pyrophosphate deposition disease (pseudogout) is entirely separate from gout—it is caused by calcium pyrophosphate crystals, not urate crystals, and oral calcium supplementation does not cause or worsen this condition. 8