What are the treatment options for an older adult with pseudogout (calcium pyrophosphate deposition disease, CPPD) and a history of joint disease or other metabolic conditions?

Treatment of Pseudogout in Older Adults with Comorbidities

For acute pseudogout attacks in older adults, intra-articular glucocorticosteroid injection (triamcinolone acetonide 60 mg) combined with joint aspiration is the optimal first-line treatment, providing rapid symptom relief with minimal systemic effects while avoiding the cardiovascular, renal, and gastrointestinal risks of NSAIDs in this vulnerable population. 1

Acute Attack Management Algorithm

First-Line: Intra-Articular Approach

• Always perform joint aspiration first to confirm CPP crystals under polarized light microscopy and exclude septic arthritis—injecting steroids into an infected joint can be catastrophic 1
• After aspiration, inject triamcinolone acetonide 60 mg (or equivalent long-acting corticosteroid) directly into the affected joint 1
• This approach has the highest strength of evidence from EULAR guidelines and provides rapid symptom relief with minimal systemic effects 1
• Combine with ice application and temporary joint rest for additional relief 1

Second-Line: Systemic Steroids (when intra-articular injection not feasible)

• Oral prednisone 0.5 mg/kg/day for 5-10 days, then discontinue without tapering if course is short 1
• Alternative: full dose for 2-5 days, then taper over 7-10 days 1
• Intramuscular triamcinolone acetonide 60 mg as single dose showed ≥50% clinical improvement in all patients within 14 days 1

Third-Line Options (with significant caveats)

• NSAIDs should be used with extreme caution in older adults due to cardiovascular, renal, and gastrointestinal risks 1
• Always assess cardiovascular, renal, and metabolic comorbidities before prescribing NSAIDs in patients over 60 1
• Evidence for NSAID use is extrapolated from gout studies, not specific CPPD trials 1
• Colchicine is less effective for acute attacks than steroids but can be considered, with risk of diarrhea and drug interactions in elderly patients with polypharmacy 1

Chronic CPPD Management

For Recurrent Attacks and Chronic Inflammatory Arthritis

• Low-dose colchicine 0.5 mg twice daily has an NNT of 2 for >30% pain reduction in chronic CPPD with knee OA, demonstrated in double-blind RCT with minimal side effects 1
• Hydroxychloroquine showed NNT of 2 for clinical response (>30% reduction in swollen/tender joint count) in 6-month RCT 1, 2
• Low-dose methotrexate 5-10 mg weekly showed excellent response in refractory cases with marked improvement within 7.4 weeks, though evidence is limited to small case series 1, 2

Dose Adjustments for Renal Impairment (Critical in Older Adults)

• Mild-moderate renal impairment (CrCl 30-80 mL/min): No dose adjustment required for colchicine, but monitor closely for adverse effects 3
• Severe renal impairment (CrCl <30 mL/min): Start colchicine at 0.3 mg/day with careful monitoring 3
• Dialysis patients: Colchicine 0.3 mg twice weekly for prophylaxis; single 0.6 mg dose for acute treatment (not repeated more than once every two weeks) 3
• Colchicine clearance is reduced by 75% in end-stage renal disease 3

Dose Adjustments for Hepatic Impairment

• Mild-moderate hepatic impairment: No dose adjustment required, but monitor closely for adverse effects 3
• Colchicine clearance may be significantly reduced and half-life prolonged in chronic hepatic impairment 3

Metabolic Screening Requirements

Who to Screen

• All patients with early-onset CPPD (age <60) or severe disease should be screened for metabolic conditions 1

What to Screen For

• Primary hyperparathyroidism (OR 3.03 for CPPD association) 1, 2
• Hemochromatosis 1, 4
• Hypomagnesemia (magnesium normally solubilizes CPP crystals and inhibits their nucleation) 1, 5, 6
• Hypophosphatasia 1
• Treat identified metabolic conditions per their respective guidelines, though whether this affects CPPD outcomes remains unclear 1

Critical Pitfalls to Avoid

• Never inject steroids without first aspirating to exclude septic arthritis in monoarticular presentations 1
• Avoid high molecular weight hyaluronan intra-articular injections, as they may induce acute CPPD attacks 1
• Do not treat asymptomatic chondrocalcinosis—it is age-related and requires no intervention 1
• Be aware that furosemide can precipitate CPPD by causing magnesium depletion 5
• Recognize drug interactions with colchicine: CYP3A4 inhibitors (clarithromycin, ketoconazole) and P-glycoprotein inhibitors (cyclosporine, ritonavir) significantly increase colchicine levels 3
• Colchicine is not removed by hemodialysis, requiring dose adjustments rather than post-dialysis supplementation 3

Key Distinction from Gout

Unlike gout, there is currently no treatment to dissolve or prevent CPP crystal formation, and all therapy is directed at controlling inflammation and symptoms 1, 5, 2. This fundamental difference means CPPD treatment is restricted to symptomatic control rather than disease modification 5, 2.