How should I manage a 67-year-old male with known calcium pyrophosphate deposition disease (pseudogout) and normal uric acid levels?

Management of Known Pseudogout with Normal Uric Acid

For a 67-year-old male with previously diagnosed pseudogout (CPPD) and normal uric acid, your management depends entirely on his current clinical presentation: if asymptomatic, no treatment is needed; if experiencing an acute attack, treat with joint aspiration plus intra-articular steroid injection for monoarticular disease or systemic corticosteroids for polyarticular disease; if having recurrent attacks, initiate prophylaxis with low-dose colchicine 0.5-1.0 mg daily. 1

Key Point About Normal Uric Acid

• The normal uric acid level confirms this is CPPD (pseudogout) and not gout, which is critical because these are distinct diseases requiring different long-term management strategies 2
• CPPD and gout can coexist, but normal uric acid makes pure gout unlikely as the primary diagnosis 3

Clinical Presentation-Based Algorithm

If Currently Asymptomatic (Intercritical Period)

• No treatment is required for asymptomatic chondrocalcinosis 1
• Screen for metabolic conditions if not previously done, particularly if disease onset was before age 60: check calcium, phosphate, magnesium, ferritin, and parathyroid hormone to rule out hyperparathyroidism, hemochromatosis, hypomagnesemia, or hypophosphatasia 3, 4
• Educate the patient about recognizing acute attacks (sudden severe joint pain, swelling, warmth) and when to seek treatment 1

If Presenting with Acute Monoarticular or Oligoarticular Attack

First-line treatment combines:

• Joint aspiration to confirm CPP crystals (positively birefringent rhomboid crystals) and exclude septic arthritis 5, 3
• Intra-articular injection of long-acting corticosteroid (triamcinolone acetonide 60 mg) immediately after aspiration 5
• Ice/cool packs and temporary rest of the affected joint 1
• This approach alone is often sufficient without systemic therapy 5

If intra-articular injection is not feasible or fails:

• Oral prednisone 0.5 mg/kg/day for 5-10 days, then discontinue (no taper needed for short courses) 5
• Alternative: single intramuscular betamethasone 7 mg or intravenous methylprednisolone 125 mg, which achieves 50% pain improvement by day 1 with NNT=3 compared to NSAIDs 1, 5

If Presenting with Acute Polyarticular Attack

• Systemic corticosteroids are first-line: oral prednisone 0.5 mg/kg/day for 5-10 days 5
• Alternative: parenteral ACTH 40-80 units IV/IM/SC three times, which resolves attacks in average 4.2 days 1, 5
• Avoid NSAIDs in this 67-year-old due to high risk of gastrointestinal bleeding, cardiovascular events, and renal impairment in older patients 1, 5

If History of Recurrent Attacks (≥2 attacks per year)

Initiate prophylaxis:

• Low-dose colchicine 0.5-1.0 mg daily reduces attack frequency from 3.2 to 1.0 per year (p<0.001), with 90% of patients benefiting 1
• Adjust colchicine dose for renal function: if CrCl <30 mL/min, start at 0.3 mg/day 5
• Monitor for diarrhea and drug interactions, especially with statins 1

If Chronic Inflammatory Arthritis with CPPD

Refer to rheumatology for consideration of:

• Low-dose oral corticosteroids (minimize dose and duration) 1
• Methotrexate or hydroxychloroquine for steroid-sparing effect 1, 3
• These patients require specialist management due to complexity 6

Critical Medication Review

Check if patient is taking furosemide or other loop diuretics:

• Furosemide causes magnesium depletion, which promotes CPP crystal formation 7
• Consider switching to alternative diuretics with less magnesium impact 7
• If furosemide is essential, supplement magnesium 7, 4

Common Pitfalls to Avoid

• Never use traditional high-dose colchicine regimens (1 mg loading then 0.5 mg every 2 hours) due to 100% incidence of severe side effects 1, 5
• Always exclude septic arthritis before injecting steroids into any joint, especially in monoarticular presentations—aspirate first 5
• Do not use NSAIDs as first-line in this 67-year-old given abundant evidence of serious toxicity (GI bleeding, cardiovascular events, renal impairment) in older patients 1, 5
• Avoid prolonged corticosteroid courses without tapering plans, as this increases adverse effects without benefit 5
• Do not assume concurrent osteoarthritis requires different treatment—manage OA symptoms with standard evidence-based OA treatments while treating CPPD-specific inflammation separately 1

Strength of Evidence Note

The majority of CPPD treatment recommendations are based on expert opinion (Level IV evidence) and extrapolation from gout studies, with only 3-4 randomized controlled trials existing specifically for CPPD 5. However, the EULAR guidelines have 79-95% strength of recommendation despite limited trial data 1.