( gold salts )
To reduce inflammation and retard
Rheumatoid arthritis and some
other forms of synovitis.
50 mg per week by intramuscular
injection for twenty weeks, then one to two injections per month thereafter.
Many doctors use smaller doses for the first two injections to test for
allergic reactions to the injections. Sometimes doctors will give more or
less than this standard dosage depending upon your body size and response to
treatment. "Maintenance" gold treatment refers to injections after the first
twenty weeks (which result in about 1,000 mg of total gold). The dosage and
duration of maintenance therapy varies quite a bit; with good responses, the
gold maintenance may be continued for many years, with injections given
every two to four weeks.
The gold salts accumulate very
slowly in the tissues of the joints and in other parts of the body. Hence,
side effects usually occur only after a considerable amount of gold has been
received, although allergic reactions can occur even with the initial
injection. The major side effects have to do with the skin, the kidneys, and
the blood cells. The skin may develop a rash, usually occurring after ten or
more injections, with big red spots or blotches, often itchy. If the rash
remains a minor problem, the drug may be cautiously continued, but
occasionally a very serious rash occurs following gold injections.
The kidney can be damaged so that protein leaks out of the body through the
urine. This is called nephrosis or the nephrotic syndrome if it is severe.
When it is recognized and the drug is stopped, the nephrosis usually goes
away, but cases have been reported in which it did not reverse.
The blood cell problems are the most dangerous. They can affect either the
white blood cells or the platelets, those blood cells that control the
clotting of the blood. In each case, the gold causes the bone marrow to stop
making the particular blood cell. If the white cells are not made, the body
becomes susceptible to serious infections that can be fatal. If the
platelets are not made, the body is subject to serious bleeding episodes
that can be fatal. These problems almost always reverse when the drug is
stopped, but reversal may take a number of weeks, during which time the
person is at risk for a major medical problem.
There are other side effects, such as ulcers in the mouth, a mild toxic
effect on the liver, or nausea, but they are usually not as troublesome.
Overall, about one-quarter of users have to stop their course of treatment
because of the side effects. One or two percent of users experience a
significant side effect; the other users don't really notice very much of a
problem, even though a serious side effect may be about to occur. Less than
one in a thousand times there may be a fatal side effect. With careful
monitoring, the drug is reasonably safe and its benefits justify its use,
since over 70% of those treated with gold show moderate or marked
improvement. However, you must maintain your respect for this treatment and
keep up regular blood tests to detect early side effects. One final note:
Most side effects occur during the initial period of twenty injections.
Serious side effects during the maintenance period are less common.
You must learn to be patient with gold treatment. The gold accumulates
slowly in the body and good responses are almost never seen in the first ten
weeks of treatment. Improvement begins slowly after that and major
improvement is usually evident by the end of 1,000 mg, or twenty weeks.
Similarly, if the drug is stopped, it requires many months before the effect
is totally lost. In one famous study, the gold group was still doing better
than the control group two years after the drug had been stopped, although
most of the effect of the drug had been lost by that time. After a side
effect, many doctors will suggest that the drug be tried again. Often, this
can be worthwhile if the approach is very cautious, since the drug is
frequently tolerated the second time around. At the Stanford Arthritis
Center we do not try gold salts again if there has been a problem with the
blood, but we will use it again cautiously after mild skin reactions or mild
amounts of protein loss through the urine.
To minimize the chance of serious side effects, most doctors recommend that
a check be made of the urine for protein leakage, of the white cells and the
platelets, and that the patient is questioned about skin rash before every
injection. This is good practice. Unfortunately, the combination of twenty
doctor visits, twenty injections, twenty urinalyses, twenty blood counts,
and so forth, makes the cost of initiating gold treatment approximately
$1,200 when pursued in this manner. There are some ways to decrease this
cost while preserving the safety. You can ask your doctor to prescribe some
test kits so that you can test your urine for protein at home. This is a
very easy technique. You can ask if it is possible to have just a platelet
smear and a white count rather than a complete blood count each time. You
can inquire whether it is possible to have the nurse give an injection after
checking the blood count without actually having a doctor visit every week.
And, some people have successfully been given their own shots at home with
the help of their family, although this is not acceptable to many. By using
such techniques, you can save half to three-quarters of the cost of a course
of gold treatment.