Gold therapy in patients with systemic lupus erythematosus

Gold therapy and its indications in dermatology. A review

Gold compounds have long been known as therapeutic agents and have been used extensively in the treatment of rheumatoid arthritis. Their mechanisms of action in vivo, however, remain unclear. In comparison to parenteral gold, the pharmacokinetics of a newly available oral compound, auranofin, differ greatly. Auranofin also appears to have specific immunomodulatory actions and to be associated with fewer and milder toxic effects. The role of chrysotherapy in dermatology has been reemphasized recently. It may be used as an adjuvant in pemphigus or other steroid-responsive diseases to help control disease activity and to taper or eliminate corticosteroid therapy more rapidly. Reports on the use of gold in dermatology are otherwise limited. They include one case of epidermolysis bullosa acquisita and psoriatic arthritis. The benefits of gold treatment have to be weighed against the risks inherent in its adverse reactions, some of which are serious and unpredictable.

Auranofin. A preliminary review of its pharmacological properties and therapeutic use in rheumatoid arthritis

Auranofin is the first orally active gold compound for the treatment of rheumatoid arthritis. Like other chrysotherapeutic agents, its exact mechanism of action is unknown, but it probably acts via immunological mechanisms and alteration of lysosomal enzyme activity. Although long term clinical experience with auranofin is limited, its efficacy appears to approach that of sodium aurothiomalate. Further comparative studies with aurothioglucose, hydroxychloroquine and D-penicillamine are required before definitive statements can be made regarding the relative efficacy of auranofin and these agents. While patients have demonstrated clinical remission of rheumatoid arthritis in response to auranofin therapy, radiological studies have been inconclusive regarding its effect on the occurrence or progression of erosive lesions. Auranofin is relatively well tolerated in most patients, but diarrhoea, skin rash, and pruritus are sometimes troublesome, and thrombocytopenia and proteinuria are potentially serious side effects which may occur during therapy. Whereas mucocutaneous side effects are more frequent with injectable gold compounds, gastrointestinal reactions are the most common adverse effect seen with auranofin. The frequency of side effects has been similar with auranofin and sodium aurothiomalate, but they are generally less severe with auranofin. While some of the side effects are controlled by a reduction in dosage, temporary or permanent withdrawal of auranofin may be necessary. Auranofin is clearly a useful addition to the limited list of agents with disease-modifying potential presently available for the treatment of rheumatoid arthritis. It will doubtless generate much interest as its final place in therapy becomes better defined through additional well-designed studies and wider clinical experience.