Calcium Pyrophosphate Deposition (CPPD)  


With Calcium Pyrophosphate Deposition (CPPD), which was formerly called pseudo-gout, the crystals that are deposited in the joints are not of uric acid, but of calcium. The acute form of CPPD is very similar to gout.

The complaints occurring in gout or CPPD are almost the same, namely painful and swollen joints due to the sudden inflammation of a joint, for example a knee, elbow or wrist. Because of the inflammation the joint hurts and becomes red, thick and stiff. The inflammation can last from a few days to weeks. Some people get an inflammation once, others get it much more often. Some inflammations are light and only last for a short time, others are very serious.

You can also suffer from CPPD if you have a hereditary predisposition or develop a metabolic disorder.

The risk of CPPD greatly increases with age, but it can occur in young people, too.

Cause of Calcium Pyrophosphate Deposition (CPPD)

CPPD occurs because calcium crystals settle on the joint. It is an acute joint inflammation with pain and swelling of one or more joints by precipitating a certain type of calcium crystals, the calcium pyrophosphate crystals, in the joint. Calcium pyrophosphate is an insoluble calcium salt. Calcium pyrophosphate is formed from pyrophosphate, which is formed by many energy-producing reactions in the body. A change in the cartilage converts pyrophosphate into calcium pyrophosphate and forms crystals over time. Crystals are thus an accumulation of this calcium salt.

The crystals can be released into the joint cavity. The joint cavity is located between two bones that together form a joint. It is not known why lime crystals settle in and around the joints. The immune system in your body then starts by cleaning up this unwanted pollution of the joints and as a result, inflammation occurs.

Causes can be
Age and reason of illness.
The disease often starts around 65 years, but CPPD can also occur at a young age in people with a hereditary predisposition or metabolic disorder, such as an iron storage disease, Wilson’s disease, a slow thyroid gland or a too strong parathyroid gland (hyperparathyroidism).
It is unknown why calcium crystals are deposited in the joints in certain people. Sometimes this can be the result of a hereditary predisposition, a metabolic disorder, a too high calcium level in the blood, too much iron in the tissues or a too low magnesium level in the blood.
However, most people with calcium pyrophosphate deposition (CPPD) do not suffer from these causes. Inflammation usually develops after a serious infection, surgery, physical injury or other stressful event.
Forms of expression. The manifestations of CPPD are different in everyone. Some people with this disease only get an inflammation once, others much more often. Some inflammations are light and only last for a short time, others are very serious. Sometimes a joint is damaged by inflammation, then the pain does not pass.
Food. It is unknown whether a diet has an effect on getting Calcium Pyrophosphate Deposition (CPPD).
Other joint disorders. Often, patients with CPPD also have other joint disorders, such as osteoarthritis.

What is the difference between gout and CPPD?
Difference in crystals. With gout uric acid crystals are deposited in the joints. With Calcium Pyrophosphate Deposition (CPPD) calcium crystals are deposited in the joints.
• The sudden attack is often less severe with CPPD than with gout.
Age. Gout is more common at a younger age (between 40 – 60 years). Calcium Pyrophosphate Deposition (CPPD) often starts around 65 years.
Development. Gout attacks often develop faster (within 6 to 24 hours) than Calcium Pyrophosphate Deposition (CPPD) attacks.
Location. CPPD often develops in large joints, such as the knee and the wrist. Gout usually develops in the big toe.
Nodules. In the case of chronic gout, nodules develop in the connective tissue of the outer ear, fingers, toes, elbows and knees. This does not happen in Calcium Pyrophosphate Deposition (CPPD).
Gender. Gout is more common in men, CPPD more in women.

Complaints with Calcium Pyrophosphate Deposition (CPPD)

The manifestations of CPPD are different in everyone. Both in the acute and the chronic form of Calcium Pyrophosphate Deposition (CPPD) a high fever may develop.
• In acute CPPD, pain is caused by the severe inflammatory reactions. This is the result of the clean-up action that the body suddenly starts up to remove the accumulated calcium crystals in and around the joints. It usually concerns the relatively larger joints of the body, such as knees, wrists, ankles and shoulders. The joints hurt, are swollen and feel warm. This causes you to have difficulty in moving around.
• In chronic CPPD the inflammation occurs very gradually. The attacks come back more often, last longer and can spread to other joints of your body. This can lead to chronic inflammations. As with acute gout, the large joints can swell and feel painful and stiff. But the inflammations can also spread to the smaller joints of your body. In Calcium Pyrophosphate Deposition (CPPD) the joints can be permanently damaged.

Recognition of Calcium Pyrophosphate Deposition (CPPD)
• the joint hurts.
• the joint is hot and thick.
• the skin around the joint is red and tense.
• you can move the joint less well.
• you may have a flu-like feeling and/or fever. This happens especially with an inflammation of a large joint, such as the knee or hip.
• inflammation caused by CPPD is always quite sudden. An attack  reaches the peak within 12 to 36 hours. After that the inflammation can last for a few days or weeks.

Usually the inflammation is in one joint, such as the knee, wrist, ankle or shoulder. If a joint only ignites once, the joint will usually not be damaged. Do inflammations return more often or do they last longer? Then the joint can be damaged. The pain often lasts for a long time. In addition to the inflammatory pain, you also have pain when moving around.

Diagnosis in Calcium Pyrophosphate Deposition (CPPD)

Your doctor will base your diagnosis on a combination of the medical history, his findings and additional test results.

At the first visit, the doctor asks you a number of questions to get a good picture of your condition. You can think of the following questions:
– When did your complaints start?
– Can you describe your complaints?
– How are your working conditions?
– What medication do you use?
– Do rheumatic diseases occur in your family?
– What is your medical history?
– Are you under the treatment of other specialists and for what?
If you have complaints, the doctor will do physical examination and blood tests and have X-rays taken. This is necessary to confirm the diagnosis.

Physical examination
A physical examination follows, looking at the affected joint. A puncture is part of this examination. In case of a puncture, the doctor will get some fluid from the inflamed joint with a prick. The doctor has the synovial fluid examined under a microscope for the presence of calcium crystals.

Blood test
To see if you do not suffer from another rheumatic disorder or a metabolic disorder usually also a blood test follows.

X-rays are taken to see if there is calcification on the joints. Calcium crystals on the joints are clearly visible on an X-ray.

Treatment Calcium Pyrophosphate Deposition (CPPD)

Unfortunately, there are no drugs that can prevent calcium crystals from being deposited on the joints. But good treatment can relieve pain, slow down inflammation and address the underlying cause. The treatment is therefore aimed at fighting the inflammations to prevent damage to the joints.

Drug treatment
Drugs without a prescription
• For the pain you can get a simple painkiller with the active ingredient paracetamol without a prescription. Paracetamol helps against pain and fever, does not cause stomach problems, usually does not cause side-effects and can be easily combined with other drugs.
• An NSAID, an anti-inflammatory analgesic in a lower dose. The abbreviation NSAID stands for Non-Steroidal Anti-Inflammatory Drugs, such as diclofenac, naproxen and ibuprofen. These painkillers inhibit inflammation.

Do you have physical complaints? Always go to your doctor or specialist for a proper diagnosis and proper treatment.

Drugs on prescription
This is provided by your doctor or rheumatologist or internist.
The aim of treating with drugs is to inhibit the immune system so that the joint inflammation stops without reducing the resistance to pathogens. Good treatment can prevent further damage to the joints. The prescribed drugs ensure that you suffer less from pain and that the inflammation of the joints is slowed down. In the choice of drugs, your doctor looks at the severity of the disease, the side effects that the drug can give and the reaction of your body to the drug. Again and again, your doctor weighs up the damage that the disease can cause to the joints and the possible side effects of a drug. How this balance goes down is different for everyone.
• A NSAID, an anti-inflammatory analgesic, such as naproxen, ibuprofen, meloxicam or indomethacin. These are drugs that are effective against inflammation, swelling, pain, stiffness and fever, but do not prevent joint damage. They do not contain corticosteroids (steroids). There is no proof that any one NSAID is better than others. Your doctor will prescribe these prescription drugs with a higher dose of the active substance. The exact effective dose varies from patient to patient. High doses of short‐acting NSAIDs give the fastest relief of symptoms. Given in the correct dose and duration, these drugs give great relief for most patients. The NSAIDs may cause stomach upset, gastrointestinal (GI) bleeding, ulcers or diarrhea, but they are well tolerated by most people when used for the short term. Some people cannot take NSAIDs because of health conditions such as ulcer disease, impaired kidney function or the use of blood thinners.
• A corticosteroid (an artificial adrenal cortex hormone) is a drug that resembles the natural hormone that the body produces in the adrenal cortex. They are anti-inflammatory drugs that suppress the immune response in the body and inflammation. A corticosteroid drug can be quickly effective for a joint swelling that is localized (not widespread) by an injection or shot into the effected joint or tendon sheath (the membrane around a tendon). The doctor may give you an injection with a corticosteroid in the shoulder, knee, elbow, wrist or ankle. Such an injection gives you relief from pain and inflammation for several weeks to months. But the symptoms can come back, because the injection of a corticosteroid only inhibits inflammation.
If the above drugs do not give a result, the doctor can switch to colchicine.
Colchicine. Colchicine is a drug active against and preventing joint inflammation and relieving pain. Colchicine can cause unpleasant side effects of the gut and must therefore be carefully dosed when prescribed. With a high dosage you can get diarrhea or dizziness. If the pain decreases, the dosage can be reduced. The doctor determines how long you should use colchicine. Contact your doctor if you experience side-effects.

Use of drugs and adherence

• It is important that you take the drugs as prescribed. In order to get your illness under control, it is very important that you take your drugs on a regular basis every day. If you do not, there is no good concentration of the drug in your blood and therefore the drug will work less well.
• Do you have trouble remembering when and how many of your drugs you should take on a daily basis and at what time of the day? Then buy a drug dispenser, in which you can sort your drugs per day.
• Do you have difficulty or objection to taking the drugs prescribed to you, for example because of possible side-effects? Then that can lead to you no longer taking the drugs regularly. Discuss this with your doctor!

Deterioration of your illness and/or complications
The doctor will look at:
• The dosage and amount of drugs you use.
• Switching to another drug in the same type or a completely new type of drug.
• Combining different drugs at the same time.

Your doctor can tell you
• whether the drug can work for you.
• how you can best use the drug.
• how much and how often you can use the drug.
• how you can best reduce the drug.

You should always tell your doctor or specialist
• if you use other drugs (bought or prescribed by another doctor).
• if you have another medical condition.
• whether you will be operated on soon.
• if you have previously been prescribed an anti-inflammatory analgesic that has caused side effects.
• whether you want to become pregnant or are pregnant.
• if you are breast-feeding.
This is important because your doctor or specialist has to make a careful choice between different drugs.

• All drugs may have side-effects when used, so ask your doctor or pharmacist what side-effects you can expect or read the leaflet.

Reduce or stop
• If you stop using a drug yourself or reduce the number of drugs yourself, your symptoms may worsen. Always consult your doctor or specialist first if you want to use less drugs or want to stop.

Alternative treatments

There are many types of alternative treatments. This refers to all treatments that fall outside normal scientific medical care. No scientific evidence has been provided for the working of these treatments. The alternative treatments are also called ‘complementary‘ because they can supplement the regular medical treatment by your doctor.
Many people choose an alternative treatment in addition to their regular medical treatment. They hope that this helps extra against their complaints or helps better to deal with the complaints.

Can an alternative treatment be a replacement for your regular medical treatment?
No, if you opt for an alternative treatment method, it is always a supplement to your regular medical treatment. You should not stop your regular treatment, because otherwise you run unnecessary health risks. Always consult your attending doctor before you start an alternative treatment.

What alternative treatments are there for example?
There are many different alternative treatment methods available, which can also be combined. Some examples are:
• Chinese medicine (acupuncture, pressure point massage, nutrition and tai chi).
• homeopathy (products made from plants and minerals).
• Bowen therapy.
• Ayurveda.
• Bach flower treatment.
• shiatsu, foot-sole and classic massage.
• Touch for Health.
• Reiki.
• dietary supplements.

What do you have to pay attention to?
• Many alternative treatments have not shown that they actually work. If you choose to try alternative treatment, make sure that your complaints do not increase. Stop an alternative treatment as soon as your symptoms increase.
• Always consider first why you want to follow an alternative treatment.
• Prepare yourself by looking up and reading information about the alternative treatment. Consult with your attending doctor, because certain complaints may be reduced by some alternative treatment methods.
• Determine yourself in which alternative method you trust for the relief of your complaints and whether you want to start.

What can you do best when choosing an alternative treatment?
• Always consult your doctor about the alternative treatment method you want to follow.
• Consult with your attending doctor and with the alternative therapist if they want to discuss your treatment with each other.
• Choose an alternative therapist who has followed a recognized vocational training and is affiliated to a professional organization.
• Ask your alternative therapist in advance about the purpose, duration, costs and risks of the treatment. How much money you spend depends on which treatment you choose and how long it takes.
• Do not stop your regular medical treatment, as this may worsen your symptoms.
• Weigh during treatment whether you want to continue or stop if your symptoms get worse, if you do not notice any effect of the alternative treatment or if you get side-effects.

Why is your food important?

• Healthy nutrition is important to get the vitamins and minerals and other nutrients that your body needs.
• Obesity creates risks for your health and disease progression. In the case of arthritis and obesity, for example, obesity plays an important role in overburdening and osteoarthritis in the knees, hips and ankles. The pressure on your joints is then simply too great. Healthy eating and exercise (exercising a sport and active in the home and outdoors) can help to reduce or prevent excess weight.
• A healthy diet is always important and the dietitian can support you with the right dietary advice.

What is a healthy diet?
With a healthy diet your body gets the right amount of good nutrients, which it needs. You eat the quantities that your body needs. The dietitian can support you with the right nutritional advice.
The 5 courses to choose from are:
• Vegetables and fruit
• Bread, cereal products and potatoes
• Fish, legumes, meat, egg, nuts and dairy
• Lubrication and preparation fats
• Drinks

Where can you get advice for a healthy diet?
• You can request advice from your doctor or a dietitian. The doctor can refer you to a dietitian. Some diets may possibly help against your symptoms. Consult with your doctor or dietitian if you want to try a certain diet. And make sure that you do not omit important foods from your daily diet.

What can you do with a painful or dry mouth?
Sometimes you can suffer from a dry or painful mouth for various reasons, also due to your illness. Tips:
• by chewing (for example piece of cucumber, sugar-free candy or chewing gum) and sucking (ice cube) the salivary glands are stimulated to produce saliva.
• good oral care is important: good tooth brushing, flossing and the use of mouthwash.
• rinse your mouth regularly, drink small amounts of water and use a mouth sprayer if necessary.
• let hot drinks cool down first.
• use ice or cold dishes, because the cold numbs the pain.
• do not use sharp herbs and spices, fruit juice, carbonated soft drinks, alcoholic beverages, very salty foods and sour food.
• food with hard crusts, nuts, bones and bones can cause injuries.
• use soup, gravy or sauce with the hot meal to make the food smoother.
• spreadable cheese, spreadable paté or salad, jam or honey on bread, porridge, drinking breakfast and custard, for example, swallows easier than dry spreads.
• if you need to use ground or liquid food, you can use a mixer to grind your meal with some extra moisture.

In some forms of arthritis or use of certain drugs intestinal complaints can occur. The intestinal complaints can arise from the influence of certain drugs on food intake. Conversely, the food you eat can have an effect on the way your drugs work.

Dietary supplements, fish fatty acids, glucosamine and vitamin D?
• Dietary supplements are available as pills, powders, drops, capsules or drinks and are intended as a supplement to inadequate daily nutrition. They contain vitamins, minerals or bio-active substances. These synthetic or isolated vitamins, minerals or bio-active substances have the same effect as the vitamins and minerals that are already naturally in your food and drink.
Many people choose an additional supplement, in addition to their daily diet. The users of dietary supplements indicate that they experience positive effects of the use of certain herbs, vitamins and minerals. The body absorbs the nutrients in pills more easily than the nutrients in food. But if you eat healthy and varied, you do not need additional nutritional supplements, because you already get enough nutrients, minerals and vitamins. Always report to your doctor and pharmacist that you are using dietary supplements.
• Fish fatty acids appear to have a mild anti-inflammatory effect with a high intake. Research has been done especially in rheumatoid arthritis. The advice is to eat oily fish twice a week.
• Glucosamine can act as a mild painkiller for osteoarthritis in the knee, but does not stop arthritis.
• Our body naturally makes vitamin D under the influence of outdoor sunlight. Vitamin D may have a beneficial effect in inflammatory arthritis, but that has not yet been proven sufficiently. People with Lupus erythematosus get vitamin D prescribed as they are not often outside, because sun exposure can lead to lupus flares and skin problems. Vitamine D is given with calcium tablets to ensure a good intake in the body, when you have osteoporosis or osteoarthritis.

Living with Calcium Pyrophosphate Deposition (CPPD)

If you suffer from a CPPD attack, you can take measures to reduce the pain:
• raise the affected joint and cool it with a wet cloth or a piece of ice in a cloth.
• try to move a little more as soon as the pain decreases.
• do not drink alcohol.
• be careful when eating protein-rich foods such as anchovies, herring, mussels, sardines and organ meats.

You can also take measures to reduce the risk of a CPPD attack:
• if you are obese, it is good to lose weight to achieve a healthy weight. Ask for a referral to a dietitian for a responsible diet and do not fall off on your own.
• drink 2 to 3 liters of water per day, so that you have to exhale more.
• it is important to keep moving during a Calcium Pyrophosphate Deposition (CPPD) attack. Keep moving the painful joints carefully, so that you do not suffer from stiffness.
• swimming, cycling or walking are good ways to stay in motion and maintain your fitness. If your complaints have lessened or stopped, you may be able to pick up a different, more taxing sport. I Joint Pain I Causes I Treatment I Prevention

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Accountability text Calcium Pyrophosphate Deposition (CPPD)
The information about Calcium Pyrophosphate Deposition (CPPD) is general.
Every situation is different, so if you have any questions or complaints, always consult your doctor, medical specialist or pharmacist.

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