Premature enthusiasm for the use of methotrexate for refractory chondrocalcinosis: comment on the article by Chollet-Janin et al

Current strategy in the treatment of calcium pyrophosphate crystal deposition disease

The paper considers currently available drugs used to treat calcium pyrophosphate crystal deposition disease. It discusses the advantages and disadvantages of the most widely used drugs, such as  nonsteroidal anti-inflammatory drugs, colchicine, glucocorticoids, traditional immunosuppressants, as well as prospects for the use of biologic agents.

Therapy for CPPD: Options and Evidence

PURPOSE OF REVIEW

Current evidence and accumulated experience for the management of calcium pyrophosphate deposition disease (CPPD) are presented.

RECENT FINDINGS

Contrary to other rheumatic inflammatory conditions that account for high interest and growing research, advances in treating CPPD are still very limited and mostly derive from those achieved in gout. Once formed, calcium pyrophosphate crystals cannot be dissolved; therefore, management relies on the control of crystal-derived inflammation. Besides classical agents-such as colchicine, glucocorticoids, or NSAIDs-the use of targeted therapies, mostly against interleukin-1, has provided a relevant relief for refractory CPPD patients in recent years. Meanwhile, former enthusiasm about conventional disease-modifying agents such as methotrexate is currently controversial.

Methotrexate: should it still be considered for chronic calcium pyrophosphate crystal disease?

Chronic calcium pyrophosphate crystal arthritis is a clinical consequence of the formation and deposition of these crystals in joints and can result in persistent arthritis. Curative treatment would require the removal of crystals from joints and tissues, but to date all agents tested have proven ineffective. Management of the inflammatory manifestations of chronic calcium pyrophosphate disease includes glucocorticoids, non-steroidal anti-inflammatory drugs, or colchicine, and responses are usually satisfactory. However, in some patients, the response to these agents is poor or they are contraindicated. Methotrexate had been reported as a promising option in small case series; however, in a recent issue of Arthritis Research & Therapy, a clinical trial failed to confirm the anticipated benefits. Here, we discuss some issues that might have influenced the results of the study, before deciding to abandon methotrexate as a therapeutic option for patients with chronic calcium pyrophosphate arthritis.

Methotrexate in chronic-recurrent calcium pyrophosphate deposition disease: no significant effect in a randomized crossover trial

INTRODUCTION

Calcium pyrophosphate deposition (CPPD) may cause severe arthropathy, major joint destruction and treatment options are limited. The aim of this study was to test the therapeutic efficacy of methotrexate (MTX) in chronic or recurrent CPPD arthropathy.

METHODS

Patients with CPPD arthropathy were randomized to receive either weekly subcutaneous injections of 15 mg/week of MTX or placebo (PBO) for three months, in a double-blind, crossover randomized controlled trial. Inclusion criteria comprised definite CPPD disease, recurrent arthritis or persistent polyarthritis, and an insufficient response to NSAIDs, glucocorticoids or colchicine. The primary outcome was an improvement in the disease activity scores based on 44 joints (DAS44). The analysis was performed on an intent-to-treat basis.

RESULTS

We randomized 26 patients, and compared 25 treatment periods on MTX with 21 treatment periods on PBO. Baseline characteristics were balanced between the groups. The evolution of the DAS44 was not statistically significantly different between groups (median DAS44 decreased by -0.08 on MTX versus -0.13 on PBO, after three months, P = 0.44). Furthermore, pain levels remained stable in both groups (median change in VAS Pain -1 unit on MTX and 0 on PBO, P = 0.43), and none of the secondary outcomes was significantly different between the two groups. Minor adverse events (AE) did not differ in frequency between the groups, but the only serious AE occurred on MTX (bicytopenia).

CONCLUSIONS

The results of this trial with MTX in this older population with chronic or recurrent CPPD arthropathy suggest no strong effect of MTX on disease activity.

TRIAL REGISTRATION

EudraCT No: 2007-003479-37. Registered 26 April 2008.

Treatment of nongout joint deposition diseases: an update

This update develops the actual therapeutic options in the management of the joint involvement of calcium pyrophosphate deposition disease (CPPD), basic calcium phosphate (BCP) deposition disease, hemochromatosis (HH), ochronosis, oxalosis, and Wilson's disease. Conventional pharmaceutical treatment provides benefits for most diseases. Anti-interleukine-1 (IL-1) treatment could provide similar results in CPPD than in gout flares. There is only limited evidence about the efficacy of preventive long-term colchicine intake, methotrexate, and hydroxychloroquine in chronic CPPD. Needle aspiration and lavage have satisfactory short and midterm results in BCP. Extracorporeal shockwave therapy has also proved its efficacy for high-doses regimes. Phlebotomy does not seem to have shown real efficacy on joint involvement in HH so far. Iron chelators' effects have not been assessed on joint involvement either, while IL-1 blockade may prove useful. NSAIDs have limited efficacy on joint involvement of oxalosis, while colchicine and steroids have not been assessed either. The use of nitisinone for ochronotic arthropathy is still much debated, but it could provide beneficial effects on joint involvement. The effects of copper chelators have not been assessed either in the joint involvement of Wilson's disease. NSAIDs should be avoided because of the liver affection they may worsen.

Methotrexate is an option for patients with refractory calcium pyrophosphate crystal arthritis

BACKGROUND

Patients with calcium pyrophosphate deposition disease sometimes require a continuous therapy. Nonsteroidal anti-inflammatory drugs, colchicine, and glucocorticoids are commonly used with good results, but occasionally, these are ineffective, contraindicated, or not tolerated. We present our experience with methotrexate (MTX) in refractory CPP arthritis.

METHODS

An observational study to describe and evaluate the use of MTX in refractory calcium pyrophosphate deposition disease was undertaken. Ten patients were included. Treatment response was evaluated by the physician (excellent, good, medium, poor, or absent response) and the patient as measured on a 10-cm visual analog scale (0 = no effect; 10 = complete resolution of symptoms). Adverse effects were recorded on all patients.

RESULTS

Five patients presented a persistent polyarthritis, 3 presented a persistent oligoarthritis, and 2 presented a very frequently recurring monoarthritis. Median MTX evaluation by patients on visual analog scale was 7.4, and physicians considered excellent (n = 2), good (n = 5), or medium (n = 3). The safety profile was generally good, but MTX was discontinued in 2 patients because of adverse effects (transient bone marrow aplasia and elevation of liver enzymes).

CONCLUSIONS

Methotrexate could be an effective and safe option for patients with refractory CPP arthritis, but additional studies are necessary to determine to what extent and for which patients MTX is effective.

Pathophysiology of articular chondrocalcinosis--role of ANKH

Calcium pyrophosphate (CPP) crystal deposition (CPPD) is associated with ageing and osteoarthritis, and with uncommon disorders such as hyperparathyroidism, hypomagnesemia, hemochromatosis and hypophosphatasia. Elevated levels of synovial fluid pyrophosphate promote CPP crystal formation. This extracellular pyrophosphate originates either from the breakdown of nucleotide triphosphates by plasma-cell membrane glycoprotein 1 (PC-1) or from pyrophosphate transport by the transmembrane protein progressive ankylosis protein homolog (ANK). Although the etiology of apparent sporadic CPPD is not well-established, mutations in the ANK human gene (ANKH) have been shown to cause familial CPPD. In this Review, the key regulators of pyrophosphate metabolism and factors that lead to high extracellular pyrophosphate levels are described. Particular emphasis is placed on the mechanisms by which mutations in ANKH cause CPPD and the clinical phenotype of these mutations is discussed. Cartilage factors predisposing to CPPD and CPP-crystal-induced inflammation and current treatment options for the management of CPPD are also described.

Anakinra is a possible alternative in the treatment and prevention of acute attacks of pseudogout in end-stage renal failure

We describe the case of a 71-year-old man with recurrent pseudogout attacks affecting multiple joints. He had end-stage renal failure that contra-indicated the use of non-steroidal anti-inflammatory drugs and was resistant to therapy with glucocorticoids. Based on the recent findings that interleukin (IL)-1beta is involved in crystal-induced inflammation, the patient received anakinra, a specific IL-1 inhibitor, in order to treat an acute attack of pseudogout. In addition, anakinra was administered as preventive therapy 3days per week after each hemodialysis session. Under this treatment, he did not present any severe episode of arthritis after a follow-up of 8 months. This observation suggests that anakinra is efficacious and safe for the prevention of crystal-induced arthritis in patients with severe renal failure.