What is the recommended treatment for an acute calcium pyrophosphate crystal arthritis (pseudogout) attack and how should recurrent disease be managed?

Pseudogout Treatment

Acute Attack Management

For acute pseudogout attacks, perform joint aspiration followed immediately by intra-articular glucocorticosteroid injection (triamcinolone acetonide 60 mg or equivalent) as first-line therapy—this provides the fastest symptom relief with minimal systemic effects. 1

Step-by-Step Approach for Acute Monoarticular/Oligoarticular Disease

• Always aspirate the joint first to confirm CPP crystals under polarized light microscopy (positively birefringent) and exclude septic arthritis before injecting steroids, as steroid injection 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 for rapid relief 2, 1
• Combine with ice application and temporary rest of the joint for additional symptom control 2, 1
• This approach has the highest strength of evidence from EULAR guidelines 1

Systemic Treatment When Intra-articular Injection Is Not Feasible

If intra-articular injection cannot be performed (polyarticular disease, inaccessible joints, patient refusal), use oral prednisone 0.5 mg/kg/day for 5-10 days as second-line therapy. 1

• For short courses (≤10 days), discontinue without tapering 1
• Alternative regimen: full dose for 2-5 days, then taper over 7-10 days 1
• Intramuscular triamcinolone acetonide 60 mg as a single dose achieved ≥50% clinical improvement in all patients within 14 days 2, 1
• Parenteral ACTH (40-80 units) three times resolved all acute attacks in an average of 4.2 days, though mild hypokalaemia and hyperglycaemia may occur 2

NSAIDs and Colchicine: Use With Extreme Caution

• Avoid NSAIDs in older adults (age >60) unless absolutely necessary due to high risk of cardiovascular events, renal impairment, and gastrointestinal bleeding 1
• Always assess cardiovascular, renal, and metabolic comorbidities before prescribing NSAIDs 1
• Evidence for NSAID efficacy is extrapolated from gout studies, not specific CPPD trials 2, 1
• Colchicine is less effective than steroids for acute attacks and carries risk of diarrhea and drug interactions in elderly patients with polypharmacy 1
• If colchicine is used, dose at 0.5 mg three to four times daily (avoid traditional high-dose regimens that cause 100% incidence of side effects) 2

Prophylaxis for Recurrent Attacks

For patients with frequent recurrent acute attacks, use low-dose colchicine 0.5 mg twice daily as prophylaxis. 2, 1

• This regimen reduced attack frequency in uncontrolled trials 2
• Alternative: low-dose NSAID with gastroprotective treatment if indicated 2
• Prophylaxis is recommended only for patients with documented recurrent attacks, not for asymptomatic chondrocalcinosis 2

Chronic CPPD Management

First-Line for Chronic CPP Crystal Inflammatory Arthritis

Low-dose colchicine 0.5 mg twice daily is the preferred first-line treatment for chronic CPPD, with an NNT of 2 for >30% pain reduction demonstrated in double-blind RCT. 1, 3

• Hydroxychloroquine showed NNT of 2 for clinical response (>30% reduction in swollen/tender joint count) in a 6-month RCT 1, 3
• NSAIDs with gastroprotective agents can be used but require careful risk-benefit assessment in older patients 2, 3

Second-Line for Refractory Chronic Disease

• Methotrexate 5-10 mg weekly for patients resistant to first-line treatments, with marked improvement within 7.4 weeks in small case series 1, 3
• Low-dose oral corticosteroids may be used when other treatments fail 2, 3
• Anakinra (IL-1 receptor antagonist) for resolution within 2 weeks in resistant cases when conventional therapies are ineffective, poorly tolerated, or contraindicated 1

CPPD with Concurrent Osteoarthritis

Manage CPPD with concurrent OA using the same evidence-based OA management guidelines, with special attention to the inflammatory component using low-dose colchicine. 2, 1

• Apply standard OA management principles including education, physical therapy, and joint protection strategies 3
• Avoid high molecular weight hyaluronan intra-articular injections as they may induce acute CPPD attacks 1, 4

Screening for Metabolic Conditions

Screen all patients with early-onset CPPD (age <60) or severe disease for primary hyperparathyroidism (OR 3.03), hemochromatosis, hypomagnesemia, and hypophosphatasia. 1, 5

• Treat identified metabolic conditions per their respective guidelines 2, 1
• Whether treating these conditions affects CPPD outcomes remains unclear 1

Critical Pitfalls to Avoid

• Never inject steroids without first aspirating to exclude septic arthritis 1, 4
• Do not treat asymptomatic chondrocalcinosis—it is age-related and requires no intervention 2
• Never use prolonged corticosteroid courses without a clear tapering plan, as this increases adverse effects without additional benefit 4
• No treatment currently dissolves or prevents CPP crystal formation—all therapy is directed at controlling inflammation and symptoms 1, 6