Acute Pseudogout Management

Treatment Options

The American College of Rheumatology recommends oral NSAIDs, oral colchicine, or systemic corticosteroids as first-line treatment for acute pseudogout attacks, with the choice depending on pain severity, number of joints involved, and patient comorbidities 1
Low-dose NSAIDs (e.g., naproxen 250 mg twice daily) with PPI if indicated can be used for treatment, and should be started early in the attack, with caution in patients with renal impairment, heart failure, peptic ulcer disease, or those on anticoagulants 1
Corticosteroids, such as oral prednisone (30-35 mg daily for 3-5 days) or intra-articular injection for 1-2 affected joints, can be used as an alternative to NSAIDs, and are recommended as the best treatment option for acute gout attacks in pregnancy 1
Combination therapy (e.g., colchicine plus NSAIDs) can be considered, and low-dose colchicine is most effective when started within 12 hours of symptom onset, with a dosing regimen of 1.2 mg initially, followed by 0.6 mg one hour later 1, 2
Topical ice application can be used as an adjunctive treatment, and prophylactic therapy with low-dose colchicine or NSAIDs reduces risk of acute gout attacks when initiating urate-lowering therapy (ULT) 1, 3

For hypertension, consider losartan (has uricosuric effects), and for hyperlipidemia, consider fenofibrate (has modest uricosuric effects) 4
Addressing associated conditions such as hyperlipidemia, hypertension, hyperglycemia, and obesity is important, as stated by the European League Against Rheumatism 4
Weight loss is recommended if obese, and limiting alcohol consumption (especially beer) and reducing intake of purine-rich foods are recommended dietary modifications 4, 1, 5, 2
Increasing consumption of low-fat dairy products and ensuring adequate hydration of at least 2 liters daily are recommended, as stated by the American College of Rheumatology 1
Engage in regular moderate physical activity, as recommended by the American College of Rheumatology 1

Urate-lowering therapy (ULT) is indicated in patients with recurrent acute attacks, arthropathy, tophi, or radiographic changes of gout, as stated by the European League Against Rheumatism and the American College of Rheumatology 4, 1, 3
Allopurinol is the appropriate first-line urate-lowering drug, with a target serum uric acid level below 360 μmol/L (6 mg/dL), according to the European League Against Rheumatism 4
High-quality evidence shows that continuing prophylaxis for more than 8 weeks is more effective than shorter durations 3

Monitoring for allopurinol toxicity, including skin rash, is important, as stated by the European League Against Rheumatism 4
Concomitant use of strong P-glycoprotein/CYP3A4 inhibitors (cyclosporin, clarithromycin, ketoconazole) is a contraindication for colchicine, and patients with renal impairment should avoid colchicine or consider reduced doses 2, 4
Evaluate gastrointestinal risk factors, and avoid NSAIDs or use with PPI if history of peptic ulcer disease or GI bleeding, with a moderate strength of evidence supporting this approach 2
Check for drug interactions, including P-glycoprotein/CYP3A4 inhibitors and concurrent statin therapy, as emphasized by the American College of Rheumatology and the European League Against Rheumatism 2, 1

Gastrointestinal adverse effects, such as dyspepsia, abdominal pain, and diarrhea, occur in 55% of patients, and headache occurs in 38% of patients 3
Corticosteroids may cause disforia, mood disorders, elevated glucose levels, immunosuppression, and fluid retention with long-term use, and skin rash is more common with corticosteroids than with NSAIDs 3, 6
High-dose colchicine regimens cause significant gastrointestinal side effects in nearly all patients, with a high strength of evidence, according to the European League Against Rheumatism 4
NSAIDs are associated with increased risk of gastrointestinal bleeding and potential cardiovascular toxicity, especially with COX-2 selective inhibitors, with a high strength of evidence, according to the American Heart Association 4
NSAIDs are associated with more gastrointestinal and non-gastrointestinal adverse events than corticosteroids 3