What is the initial treatment for a patient with meniscal calcifications and pseudogout?

Initial Treatment for Meniscal Calcifications and Pseudogout

For a patient with meniscal calcifications and acute pseudogout, perform joint aspiration to confirm calcium pyrophosphate crystals and exclude infection, then immediately inject intra-articular triamcinolone acetonide 60 mg into the affected joint for optimal first-line treatment. 1

Immediate Management Algorithm

Step 1: Joint Aspiration (Mandatory First Step)

• Always aspirate the joint before any steroid injection to confirm CPP crystals under polarized light microscopy and exclude septic arthritis, as injecting steroids into an infected joint can be catastrophic 1
• Look for positively birefringent rhomboid-shaped CPPD crystals under compensated polarized light microscopy 2
• Send fluid for Gram stain and culture since pseudogout can coexist with septic arthritis 3

Step 2: Intra-articular Corticosteroid Injection (First-Line)

• Inject triamcinolone acetonide 60 mg (or equivalent long-acting corticosteroid) directly into the affected joint immediately after aspiration 1
• This approach has the highest strength of evidence from EULAR guidelines and provides rapid symptom relief with minimal systemic effects 1
• All patients in prospective studies showed ≥50% clinical improvement within 14 days, with major improvement occurring by Day 3-4 in most cases 4
• Add ice application and temporary rest of the joint for additional relief 1

Step 3: Systemic Steroids (Second-Line When Injection Not Feasible)

• If intra-articular injection is not feasible (polyarticular involvement, patient refusal, technical difficulty), use oral prednisone 0.5 mg/kg/day for 5-10 days, then discontinue without tapering if course is short 1
• Alternative: intramuscular triamcinolone acetonide 60 mg as a single dose showed ≥50% clinical improvement in all patients within 14 days 1, 4
• For severe polyarticular attacks where multiple intra-articular injections are impractical, systemic steroids are reasonable 4

Alternative Acute Treatments (Use With Extreme Caution)

NSAIDs

• Use NSAIDs 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

• Colchicine is less effective for acute pseudogout attacks than steroids but can be considered 1
• Risk of diarrhea and drug interactions in elderly patients with polypharmacy 1
• The FDA-approved dosing for acute attacks is 1.2 mg immediately followed by 0.6 mg one hour later (total 1.8 mg), though this is primarily validated for gout 5

IL-1 Inhibitors

• Anakinra (IL-1 receptor antagonist) showed resolution of signs and symptoms within 2 weeks in resistant pseudogout cases 6
• Consider only when conventional therapies are ineffective, poorly tolerated, or contraindicated 7

Critical Distinctions and Pitfalls

Key Differences from Gout

• Unlike gout, there is currently no treatment to dissolve or prevent CPP crystal formation—all therapy is directed at controlling inflammation and symptoms 1
• Meniscal calcifications (chondrocalcinosis) on imaging are characteristic of pseudogout, not gout 7, 2
• Pseudogout characteristically affects larger joints like the knee, while gout typically affects the first metatarsophalangeal joint 3

Common Pitfalls to Avoid

• Never assume infection is excluded without joint aspiration in monoarticular presentations before steroid injection 1
• Do not treat asymptomatic chondrocalcinosis—it is age-related and requires no intervention 1
• Avoid high molecular weight hyaluronan intra-articular injections, as they may induce acute CPPD attacks 1

Screening for Underlying Causes

• Screen all patients with early-onset CPPD (age <60) or severe disease for primary hyperparathyroidism (OR 3.03 for CPPD association), hemochromatosis, hypomagnesemia, and hypophosphatasia 1, 2
• Treat identified metabolic conditions per their respective guidelines 1