Diagnostic Imaging and Management of CPPD

Initial Imaging and Diagnosis

Radiography is recommended as the initial imaging method for suspected CPPD, which can show chondrocalcinosis, tendon, ligament, and capsular calcification, particularly in target sites such as the triangular fibrocartilage, knee menisci, symphysis pubis, and labrum at the pelvis, as well as characteristic arthropathy affecting radiocarpal, metacarpophalangeal, and patellofemoral joints, as recommended by the American College of Radiology 1
Ultrasound can complement radiography by showing intra-articular microtophi, echogenic synovial hypertrophy, and "icing" of cartilage (double contour sign) with 83% sensitivity and 76% specificity 1
Confirm CPPD diagnosis through synovial fluid analysis for CPP crystals, radiographic findings, and ultrasonography, as recommended by the European League Against Rheumatism 2
Synovial fluid analysis should include identification of weakly positive birefringent rhomboid-shaped crystals under compensated polarized light microscopy, as recommended by the European League Against Rheumatism 2

The initial management of CPPD should focus on joint aspiration with intra-articular glucocorticoid injection for acute attacks, followed by NSAIDs with gastroprotection or low-dose colchicine for ongoing management, as recommended by the American College of Rheumatology 2
First-line treatment options include NSAIDs with gastroprotection or low-dose colchicine (0.5-1.0 mg daily), with a NNT of 2 at 4 months for >30% pain reduction, as suggested by the American College of Rheumatology 2

The preferred pharmacological options, in order, are:

For chronic inflammatory arthritis, start with NSAIDs/colchicine, and if ineffective, move to low-dose corticosteroids, and if still ineffective, move to methotrexate or hydroxychloroquine, with a low strength of evidence 2
Second-line treatment options include low-dose corticosteroids, and third-line options include methotrexate (5-10 mg/week) and hydroxychloroquine, with a NNT for clinical response of 2 (95% CI 1 to 7), as recommended by the European League Against Rheumatism 2

Elderly patients have a higher risk of toxicity with NSAIDs and colchicine, and require careful monitoring, as recommended by the American Geriatrics Society 2
Renal impairment increases the risk of adverse effects, and requires dose adjustment, as suggested by the National Kidney Foundation 2
Early-onset disease (before age 60) requires a thorough metabolic workup, particularly for hemochromatosis, as recommended by the European League Against Rheumatism 2

The primary goals of treatment are to reduce joint pain and stiffness, maintain/improve joint mobility, reduce physical disability, and improve quality of life, as recommended by the American College of Rheumatology 2
Regular follow-up is necessary to assess treatment response, monitor for medication side effects, evaluate for progression of joint damage, and reassess for any underlying metabolic disorders, as suggested by the European League Against Rheumatism 2

NSAIDs carry a risk of gastrointestinal bleeding, cardiovascular events, and renal impairment, with a high strength of evidence 2
Colchicine carries a risk of diarrhea and other gastrointestinal side effects, and high-dose regimens should be avoided, with a moderate strength of evidence 2
Parenteral glucocorticoids may cause mild hypokalaemia, hyperglycaemia, and fluid retention, with a low strength of evidence 2
IV methylprednisolone (125 mg) provides rapid relief of symptoms in acute crystal-induced arthritis when oral medications are ineffective or contraindicated, with a NNT of 3 compared to oral NSAIDs, and a high strength of evidence 2
IM betamethasone (7 mg) is an alternative injectable option with similar efficacy to IV methylprednisolone, with a moderate strength of evidence 2