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Recurrent acute calcium pyrophosphate crystal arthritis — SCE Rheumatology MCQ

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ModerateFlare ProphylaxisRecurrent acute calcium pyrophosphate crystal arthritisSCE Rheumatology

A 72-year-old man has experienced five attacks of acute arthritis affecting his knees and wrists over 9 months. Two attacks were aspirated; both showed intracellular calcium pyrophosphate crystals, with negative Gram stain and culture. Radiographs show bilateral knee and triangular fibrocartilage chondrocalcinosis. Each attack resolves completely, and he has no synovitis, pain or morning stiffness between episodes. Adjusted calcium, magnesium, phosphate, alkaline phosphatase, ferritin, transferrin saturation, parathyroid hormone and thyroid function are normal. His eGFR is 78 mL/min/1.73 m², liver function and full blood count are normal, and he takes no CYP3A4 or P-glycoprotein inhibitor. He takes apixaban for atrial fibrillation and previously required endoscopic treatment for a bleeding gastric ulcer. He wishes to reduce the risk of further attacks. Which long-term pharmacological strategy is most appropriate?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Colchicine 500 micrograms once or twice daily

Explanation lettering: C = shown as B · B = shown as C · E = shown as D · D = shown as E

This is recurrent acute CPP crystal arthritis rather than chronic inflammatory CPPD: attacks are frequent, crystal-proven and separated by completely asymptomatic intervals. EULAR recommends low-dose colchicine, 0.5–1.0 mg daily, as prophylaxis against recurrent acute CPP crystal arthritis. His preserved renal and hepatic function and absence of relevant metabolic inhibitors make colchicine a suitable choice, although its use for CPPD should be discussed as off-label in UK practice. Hydroxychloroquine (A) and methotrexate (B) are potential options for persistent chronic inflammatory CPPD, not first-line prophylaxis for discrete acute attacks without intercritical synovitis. Long-term low-dose prednisolone (C) may also be considered for chronic inflammatory CPPD when preferable treatments are unsuitable, but exposes this patient to cumulative glucocorticoid toxicity without being the preferred prophylactic strategy. A low-dose NSAID with gastroprotection (D) is an alternative identified by EULAR, but is less appropriate here because previous peptic ulcer bleeding and concurrent apixaban confer substantial haemorrhagic risk; a proton-pump inhibitor does not remove that risk. Colchicine therefore provides the best balance of phenotype-specific efficacy and individual safety.

Reference: EULAR recommendations for calcium pyrophosphate deposition. Part II: management (20 January 2011) — https://pubmed.ncbi.nlm.nih.gov/21257614/ Recent advances in the therapeutic management of calcium pyrophosphate deposition disease (11 March 2024) — https://pubmed.ncbi.nlm.nih.gov/38529115/ Eliquis 5 mg film-coated tablets: Summary of Product Characteristics (17 August 2026) — https://www.medicines.org.uk/emc/product/2878/smpc