Pseudogout, formally known as Calcium Pyrophosphate Deposition (CPPD) disease, is a form of arthritis that causes sudden, intense joint inflammation. The condition gets its name because its symptoms closely resemble those of gout, but it is caused by the accumulation of calcium pyrophosphate dihydrate crystals within the joints and surrounding tissues. These crystal deposits trigger an inflammatory response that leads to painful episodes called flares, most commonly affecting the knees, wrists, and shoulders. While there is no current treatment to dissolve the crystals, managing the condition focuses on controlling acute flares and addressing long-term joint health.
Immediate Treatment for Acute Flares
The primary goal during an acute pseudogout flare is to rapidly reduce inflammation and relieve severe joint pain. Treatment must begin quickly, often within the first 12 to 36 hours of symptom onset, for maximum effectiveness.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs), such as indomethacin or naproxen, are often prescribed at full therapeutic doses to control inflammation and pain. Due to the risk of gastrointestinal or kidney issues, particularly in older individuals, a healthcare provider must carefully consider their use.
Colchicine is another medication used to treat acute attacks by interfering with the inflammatory process triggered by the crystals. A low-dose regimen (e.g., 1.2 mg initially followed by 0.6 mg one hour later) is now recommended for treating flares. This protocol is as effective as older, high-dose protocols but causes significantly fewer gastrointestinal side effects. Colchicine can also be used at a lower daily dose for patients experiencing frequent attacks to help reduce future episodes.
For severe, localized flares, particularly in a single, large joint, a highly effective treatment involves a joint aspiration and injection. The procedure, called arthrocentesis, removes excess fluid from the joint, which immediately reduces pressure and pain. This also confirms the diagnosis by identifying the crystals. Following fluid removal, a corticosteroid is often injected directly into the joint space to deliver a powerful anti-inflammatory effect.
Oral corticosteroids, such as prednisone, are an alternative for patients who cannot take NSAIDs or colchicine, or for those with multiple joints affected simultaneously. A short course of oral steroids can quickly suppress widespread inflammation. In rare cases of severe, treatment-resistant pseudogout, a physician may consider using advanced therapies like Interleukin-1 (IL-1) inhibitors.
Managing Underlying Conditions and Chronic Joint Issues
Long-term management of CPPD extends beyond treating acute flares to addressing the underlying causes and the resulting chronic joint damage. Pseudogout is often associated with other metabolic or endocrine disorders, making it important to screen for these conditions, as treating them may help reduce the frequency of flares. For example, conditions like hyperparathyroidism, which affects calcium levels, and hemochromatosis, an iron overload disorder, have been linked to an increased risk of CPPD.
Testing for and correcting mineral imbalances, such as low magnesium levels (hypomagnesemia), can also be a component of long-term management, as low magnesium may promote crystal formation. There is no medication that can dissolve or remove the existing calcium pyrophosphate crystals, so the focus remains on controlling inflammation and managing symptoms.
Repeated inflammatory episodes and the persistent presence of crystals can lead to chronic joint degeneration, a condition known as pyrophosphate arthropathy, which resembles osteoarthritis. Management of this chronic damage often involves non-pharmacological interventions like physical therapy to maintain joint mobility and strengthen surrounding muscles. In cases of severe joint destruction and persistent pain, surgical options, such as joint replacement, may become necessary.
Lifestyle Adjustments and Supportive Home Care
Simple, non-pharmacological strategies are important for managing symptoms during a flare and supporting overall joint health. During an acute attack, it is helpful to rest and immobilize the affected joint to reduce irritation of the inflamed tissues. Using a cane or crutch can help take weight off a painful knee or ankle during a severe episode, preventing further trauma.
Applying cold therapy, such as ice packs, to the joint for 15 to 20 minutes several times a day can help reduce the swelling and intense warmth associated with the acute inflammation. Conversely, for chronic stiffness outside of a flare, applying heat may help soothe the joint and improve muscle relaxation.
Maintaining a healthy lifestyle is also beneficial, although specific dietary restrictions used for true gout are not effective for pseudogout. Staying well-hydrated is generally recommended, as sufficient fluid intake supports joint health. Maintaining a healthy body weight is also important to lessen the strain on weight-bearing joints like the knees, which are frequently affected by CPPD.
Diagnosis and When to Consult a Specialist
Confirming a diagnosis of pseudogout is essential because its symptoms mimic those of other conditions like septic arthritis or true gout. The most definitive diagnostic method is joint fluid aspiration, where a sample of fluid is withdrawn from the affected joint using a needle. This fluid is then examined under a polarized microscope to identify the characteristic, positively birefringent calcium pyrophosphate crystals.
A specialist, typically a rheumatologist, is the most appropriate provider for managing chronic or complex cases of CPPD. They can guide the long-term treatment strategy, manage associated metabolic conditions, and determine the need for prophylactic medication like low-dose colchicine to prevent recurrent flares.
It is important to seek immediate medical attention if a flare is accompanied by signs of a possible joint infection, such as a high fever, chills, or rapid, extreme worsening of pain. A prompt medical evaluation is necessary to rule out septic arthritis, as this condition requires immediate antibiotic treatment.