Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

mono- or oligoarticular disease

1st line – intra-articular corticosteroids

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints accessible to injection
1st line – 

intra-articular corticosteroids

Preferred treatment and are generally well tolerated.[52]​ Although their mechanism of action is not fully elucidated, their potent anti-inflammatory action is likely involved.

The treatment should be given at the time of diagnosis. Before injection, synovial fluid should be removed from the affected joint to minimize dilution of the drug.

Lidocaine is typically used as a local anesthetic.

Dose can be repeated every 3 months.

Primary options

dexamethasone sodium phosphate: large joints: 40-80 mg intra-articularly as a single dose; small joints: 10-20 mg intra-articularly as a single dose

OR

triamcinolone acetonide: large joints: 10-40 mg intra-articularly as a single dose; small joints: 5-10 mg intra-articularly

Consider – acetaminophen

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints accessible to injection
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints inaccessible or declines injection
1st line – 

nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are effective but should be used cautiously in older patients.[50]

Should be used with preventive measures, such as proton-pump inhibitors, in patients at high risk of gastrointestinal complications.[53]

COX-2 inhibitors may be less likely to cause gastrointestinal bleeding than traditional NSAIDs in patients with a history of gastrointestinal bleeding or comorbidities but have been associated with increased risks of cardiovascular events.[54][55]

Primary options

sulindac: 200 mg orally twice daily for 7-10 days

OR

naproxen: 500 mg orally twice daily for 10-14 days

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily for 10-14 days

OR

meloxicam: 7.5 to 15 mg orally once daily for 10-14 days

OR

celecoxib: 100-200 mg orally twice daily for 10-14 days

Consider – acetaminophen

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints inaccessible or declines injection
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – colchicine

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints inaccessible or declines injection
2nd line – 

colchicine

Patients with osteoarthritis-like disease or rheumatoid-like disease (i.e., where there is an inflammatory component to the arthritis) may benefit from low-dose colchicine therapy, if kidney and liver function are normal.[56] Evidence for colchicine use in CPPD is mostly extrapolated from evidence for the treatment of acute gout.[50]​​

Minimum effective dose should be used because of the narrow benefit-to-risk index.[57]

May be safer than nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with a history of gastrointestinal bleeding or comorbidities.

Colchicine may be given daily or every 3-4 days depending on the frequency of attacks.

Primary options

colchicine: 0.6 mg orally once or twice daily, maximum 1.8 mg/day

Consider – acetaminophen

Back
ACUTE
|
mono- or oligoarticular disease
|
with joints inaccessible or declines injection
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – systemic corticosteroids

Back
ACUTE
|
mono- or oligoarticular disease
|
treatment failure/contraindication
1st line – 

systemic corticosteroids

Reserved for when intra-articular corticosteroid injections have failed or are not tolerated, and nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine are contraindicated.

Dosing regimens remain unstudied but there is little evidence that doses >20 mg/day of prednisone are warranted, and lower doses may also be effective.[58]

Long-term corticosteroid use can cause a variety of adverse effects. To minimize the osteoporosis that can develop, these drugs should be given with calcium and vitamin D supplements, and bone densities should be followed yearly.

Other adverse effects such as cataracts, weight gain, and type 2 diabetes mellitus are less controllable. Minimum doses should be sought and risk-to-benefit ratios weighed carefully for these drugs.

One randomized controlled trial conducted between 2018 and 2022 found that, when compared with colchicine, prednisone showed equivalent short-term efficacy for the treatment of acute CPP crystal arthritis in hospitalized patients.[59]

Primary options

prednisone: 10-20 mg orally once daily, decrease by 5-10 mg/day every 3 days until discontinuation

Consider – acetaminophen

Back
ACUTE
|
mono- or oligoarticular disease
|
treatment failure/contraindication
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – combination of analgesics/joint aspiration/splinting

Back
ACUTE
|
mono- or oligoarticular disease
|
treatment failure/contraindication
2nd line – 

combination of analgesics/joint aspiration/splinting

A combination of analgesics, joint aspiration, splinting, and observation may be the safest option for some patients.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) twice daily when required

polyarticular disease

1st line – nonsteroidal anti-inflammatory drugs (NSAIDs)

Back
ACUTE
|
polyarticular disease
|
initial treatment
1st line – 

nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are effective but should be used cautiously in older patients.[50]

Should be used with preventive measures, such as proton-pump inhibitors, in patients at high risk of gastrointestinal complications.[53]

COX-2 inhibitors may be less likely to cause gastrointestinal bleeding than traditional NSAIDs in patients with a history of gastrointestinal bleeding or comorbidities but have been associated with increased risks of cardiovascular events.[54][55]

Primary options

sulindac: 200 mg orally twice daily for 7-10 days

OR

naproxen: 500 mg orally twice daily for 10-14 days

OR

diclofenac potassium: 50 mg orally (immediate-release) two to three times daily for 10-14 days

OR

meloxicam: 7.5 to 15 mg orally once daily for 10-14 days

OR

celecoxib: 100-200 mg orally twice daily for 10-14 days

Consider – acetaminophen

Back
ACUTE
|
polyarticular disease
|
initial treatment
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – colchicine

Back
ACUTE
|
polyarticular disease
|
initial treatment
2nd line – 

colchicine

Patients with osteoarthritis-like disease or rheumatoid-like disease (i.e., where there is an inflammatory component to the arthritis) may benefit from low-dose colchicine therapy, if kidney and liver function are normal.[56] Evidence for colchicine use in CPPD is mostly extrapolated from evidence for the treatment of acute gout.[50]​​

Minimum effective dose should be used because of the narrow benefit-to-risk index.[57]

May be safer than nonsteroidal anti-inflammatory drugs (NSAIDs) in patients with a history of gastrointestinal bleeding or comorbidities.

Colchicine may be given daily or every 3-4 days depending on the frequency of attacks.

Primary options

colchicine: 0.6 mg orally once or twice daily, maximum 1.8 mg/day

Consider – acetaminophen

Back
ACUTE
|
polyarticular disease
|
initial treatment
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

1st line – systemic corticosteroids

Back
ACUTE
|
polyarticular disease
|
treatment failure/contraindication
1st line – 

systemic corticosteroids

Used when treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) or colchicine has failed or is contraindicated.

Dosing regimens remain unstudied but there is little evidence that doses >20 mg/day of prednisone are warranted, and lower doses may also be effective.[58]

Long-term corticosteroid use can cause a variety of adverse effects. To minimize the osteoporosis that can develop, these drugs should be given with calcium and vitamin D supplements, and bone densities should be followed yearly.

Other adverse effects such as cataracts, weight gain, and type 2 diabetes mellitus are less controllable. Minimum doses should be sought and risk-to-benefit ratios weighed carefully for these drugs.

One randomized controlled trial conducted between 2018 and 2022 found that, when compared with colchicine, prednisone showed equivalent short-term efficacy for the treatment of acute CPP crystal arthritis in hospitalized patients.[59]

Primary options

prednisone: 10-20 mg orally once daily, decrease by 5-10 mg/day every 3 days until discontinuation

Consider – acetaminophen

Back
ACUTE
|
polyarticular disease
|
treatment failure/contraindication
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

2nd line – intra-articular corticosteroids

Back
ACUTE
|
polyarticular disease
|
treatment failure/contraindication
2nd line – 

intra-articular corticosteroids

Used when treatment with nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or systemic corticosteroids has failed or is contraindicated.

Before injection, synovial fluid should be removed from the affected joint to minimize dilution of the drug.

Lidocaine is typically used as a local anesthetic.

Dose can be repeated every 3 months.

Primary options

dexamethasone sodium phosphate: large joints: 40-80 mg intra-articularly as a single dose; small joints: 10-20 mg intra-articularly as a single dose

OR

triamcinolone acetonide: large joints: 10-40 mg intra-articularly as a single dose; small joints: 5-10 mg intra-articularly

Consider – acetaminophen

Back
ACUTE
|
polyarticular disease
|
treatment failure/contraindication
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

3rd line – combination of analgesics/joint aspiration/splinting

Back
ACUTE
|
polyarticular disease
|
treatment failure/contraindication
3rd line – 

combination of analgesics/joint aspiration/splinting

A combination of analgesics, joint aspiration, splinting, and observation may be the safest option for some patients.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

OR

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) twice daily when required

ONGOING

chronic recurrent involvement of knee, hip, or shoulder joint with severe degeneration

1st line – joint replacement surgery

Back
ONGOING
|
chronic recurrent involvement of knee, hip, or shoulder joint with severe degeneration
1st line – 

joint replacement 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.[11]

Consider – acetaminophen

Back
ONGOING
|
chronic recurrent involvement of knee, hip, or shoulder joint with severe degeneration
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

with osteoarthritis-like disease or rheumatoid-like disease

1st line – maintenance therapy with colchicine

Back
ONGOING
|
with osteoarthritis-like disease or rheumatoid-like disease
1st line – 

maintenance therapy with colchicine

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.

Minimum effective dose should be used because of the narrow benefit-to-risk index.[57]

Primary options

colchicine: 0.6 mg orally once or twice daily, maximum 1.8 mg/day

Consider – acetaminophen

Back
ONGOING
|
with osteoarthritis-like disease or rheumatoid-like disease
Consider – 

acetaminophen

Treatment recommended for SOME patients in selected patient group

Simple analgesics, such as acetaminophen, may be used for pain relief.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer