Approach
The major goals of therapy for patients with CPP arthritis are reduction in pain and improved function of the affected joints. There is little evidence that rapid therapy alters the natural history of the disease. Simple analgesics, such as paracetamol, are used to control pain at any stage of the disease.[53] Cool packs, ice, and temporary joint rest may help to relieve symptoms. Comorbidities identified during symptom evaluation (e.g., hyperparathyroidism, haemochromatosis, hypomagnesaemia, hypophosphatasia) should be treated.[53] See Hyperparathyroidism (Management) and Hemochromatosis (Management).
Mono-articular or oligo-articular disease
Intra-articular corticosteroids are the preferred treatment during an acute attack. They have been shown to reduce pain and limit the duration of inflammation.[54][55] They are generally well tolerated, although bleeding into the skin or joint and infection can rarely occur.[55] Although their mechanism of action is not fully elucidated, their potent anti-inflammatory action is probably involved.
Triamcinolone hexacetonide is the longest acting of the commonly used intra-articular corticosteroid preparations. Dexamethasone and triamcinolone acetonide are also used. The treatment should be given at the time of diagnosis and can be repeated every 3 months. Before injection, synovial fluid should be removed from the affected joint to minimise dilution of the drug. Lidocaine is typically used as a local anaesthetic.
For patients where intra-articular corticosteroid injections are not practical or declined, systemic therapies can be considered. Non-steroidal anti-inflammatory drugs (NSAIDs) can be useful in reducing pain and inflammation but should be prescribed cautiously in older patients.[53] They should be used with preventive measures, such as proton-pump inhibitors, in patients at high risk of gastrointestinal complications.[56] COX-2 inhibitors (e.g., celecoxib) may be less likely to cause gastrointestinal bleeding than traditional NSAIDs in patients with a history of gastrointestinal bleeding or comorbidities.[57] All NSAIDs have been associated with increased risks of cardiovascular events.[58]
Patients with osteoarthritis-like disease or rheumatoid-like disease (i.e., where there is an inflammatory component to the arthritis) who cannot take NSAIDs may benefit from low-dose colchicine therapy, if kidney and liver function are normal.[59] Evidence for colchicine use in CPPD is mostly extrapolated from evidence for the treatment of acute gout.[53] Colchicine has a narrow therapeutic window. To avoid adverse effects, particularly diarrhoea, the minimum effective dose should be used due to the narrow benefit-to-risk index.[60]
Polyarticular disease
For patients with polyarticular disease, systemic therapies are first-line therapy, followed by intra-articular corticosteroids.
Treatment failure/contraindications
Systemic corticosteroids at moderate-to-low doses can be used when other therapies are not effective or are contraindicated.[61] Alternatively, a combination of pain medicines, joint aspiration, splinting, and observation may be the safest option for some patients. One randomised controlled trial conducted between 2018 and 2022 found that, when compared with colchicine, prednisolone showed equivalent short-term efficacy for the treatment of acute CPP crystal arthritis in hospitalised patients.[62]
Surgery
Patients with chronic or recurrent involvement of the knee, hip, or shoulder associated with severe joint degeneration may be good candidates for joint replacement surgery.[14]
Maintenance therapy
Patients with an inflammatory component to their disease who display a positive response to colchicine in terms of reduced severity or frequency of attacks may benefit from a low dose of colchicine to prevent further attacks.
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