Monitoring serum gold values to improve chrysotherapy in rheumatoid arthritis

On the course of seropositive rheumatoid arthritis during and after long-term gold therapy

The purpose of the present study was to get an estimate on the course of seropositive RA in 93 patients, who had been in chrysotherapy for at least 3 years up to 13 years. The study was observational with assessment once a year by the same physician. After one year the median number of swollen joints had decreased from six to two (p = 0.0001), and the median number of tender joints from five to two (p = 0.0001). This improvement was maintained throughout the period. A decrease in median erythrocyte sedimentation rate from 34 mm/h to 15 mm/h remained significant for 10 years, although the ESR gradually increased throughout the period. An increase in median hemoglobin from 7.8 mmol/l to 8.5 mmol/l lasted for 7 years. Contrastingly, the number of joints with limited motion increased from a median score of 4 to a median score of 20 (p = 0.0001). Radiographical changes progressed from a median score of 18 to a median score of 84 (p = 0.0001). Significant correlations were found between the ESR, joint tenderness score and limitation of motion score at the year 1, and later progression of limitation of motion score, but too weak to be of predictive importance. In conclusion early symptomatic improvement of rheumatoid arthritis during gold treatment can be stable during several years, but progression in the number of joints with limited motion and radiographical changes continues.

Clinical pharmacokinetics of drugs used in juvenile arthritis

Juvenile arthritis is defined as the occurrence of objective evidence of arthritis for a minimum of 6 weeks, in a child 16 years of age or younger. With a reported incidence of 9 to 19.6 per 100,000 children, juvenile arthritis is considered to be a rare disease. There is no known cure; however, up to 75% of patients will undergo remission by late adolescence. Drugs used in the treatment of juvenile arthritis are divided into 2 major classes: (a) the nonsteroidal anti-inflammatory drugs (NSAIDs) including salicylates, naproxen, ibuprofen, fenoprofen, ketoprofen, flurbiprofen, indomethacin, sulindac, tolmetin and diclofenac, and (b) disease modifying agents which encompass drugs such as antimalarial agents, gold, methotrexate, penicillamine and sulfasalazine. In almost all the reports dealing with the pharmacokinetics of NSAIDs, the level of disease activity has not been noted. The level of activity is important since, during a flare, the plasma albumin may fall to the point that it causes a substantial and clinically significant increase in the unbound serum concentration of highly bound drugs. The relationship between the concentration of these drugs in the systemic circulation and their efficacy is not clear. However, for many of them, therapeutic drug monitoring is recommended as a means of reducing the possibility of toxic reactions. Further pharmacokinetic and -dynamic evaluations are needed for many of these drugs in juvenile arthritis.

The efficacy and safety of auranofin in the treatment of juvenile rheumatoid arthritis. A long-term open study

The safety and efficacy of auranofin in the long-term treatment of children with juvenile rheumatoid arthritis was investigated in an open study of 14 patients. Twelve patients completed at least 12 months of treatment, and 7 patients completed 36 months of treatment. Classic parameters of disease activity showed improvement over baseline values after 6 months of treatment, and laboratory indices remained stable or improved throughout the study. Auranofin was well tolerated; the frequency of adverse effects was lower in these patients than has been previously reported in either adults or children whose arthritis has been treated with injectable gold.

Gold-induced aplastic anemia

Three patients receiving gold salt treatment for rheumatoid arthritis developed severe aplastic anemia. All three patients experienced remission of their disease at the time of the occurrence of marrow aplasia. Reviewing data on these patients and recent literature indicate that fatal marrow aplasia seems to occur more frequently in sero-negative women who respond well to therapy with gold salts. Frequent blood monitoring in search for any pronounced or sustained drop in red, white or platelet count, even within normal range could serve as a warning sign for myelotoxicity. Despite intensive supportive measures and specific therapeutic attempts, all three patients eventually died of septic shock.

Lack of correlation between blood gold concentrations and clinical response in patients with definite or classic rheumatoid arthritis receiving auranofin or gold sodium thiomalate

We investigated the correlation between whole blood gold concentrations and clinical outcomes in 59 auranofin-treated patients and 51 gold sodium thiomalate-treated patients who completed a 21-week, placebo-controlled, multicenter parallel trial. Whole blood gold concentrations did not correlate with clinical outcome, as assessed by changes in joint tenderness, joint swelling, or Westergren erythrocyte sedimentation rate. They also did not correlate with toxic reactions necessitating withdrawal from the study.

Tissue disposition and excretion of gold and 14C in rats treated with sodium aurothio[1,4-14C]malate or thio [1,4-14C] malic acid

In rats injected intramuscularly with sodium aurothio[1,4-14C]malate, 80% of the 14C was excreted in the urine, mostly in 24 h, 2% in the faeces and 10% as 14CO2 in the expired air during the first six hours with none thereafter. Urinary and faecal gold represented 5% and 2.5% of the dose, respectively. In rats given thio[1,4-14C]malic acid, 50% of the 14C was excreted in the urine, 10% in the expired air as 14CO2 and 2% in the faeces. Radioactivity was found in all tissues with distribution similar for the two compounds, the major sites of accumulation being bone, kidney and liver. Significantly higher amounts of 14C were found in the 14C-aurothiomalate-dosed animals, notably in bone and kidney. Gold was located principally in kidney, liver, lung and spleen with smaller amounts elsewhere. At least seven radioactive metabolites (including sodium aurothiomalate and thiomalic acid) were present in the urine of rats given 14C-aurothiomalate. Urine from 14C-thiomalic acid-treated rats contained at least five radiolabelled compounds, one of which was thiomalic acid. Results show that most of the gold was removed from the thiomalate moiety, however, the 14C distribution and the radioactive metabolites in urine demonstrated that some intact aurothiomalate remains.

An attempt to predict the response to gold therapy in rheumatoid arthritis

In 54 rheumatoid arthritis patients undergoing conventional chrysotherapy, we prospectively sought predictors of response, using strict clinical and laboratory criteria of improvement. Forty-five patients who completed 6-12 months of therapy were classified into 3 outcome categories: group 0, not significantly improved (18 patients); group 1, improved (18 patients); and group 2, markedly improved (9 patients). Sixty-two entry variables were tested in univariate and multivariate analysis for predictor function. No continuous variable was predictive. The discrete variables HLA-A3 positivity and HLA-DR4 negativity were the best predictors of response to gold. In a multivariate analysis using these 2 univariates (A3 and DR4) plus hemoglobin, we developed a discriminant function that correctly predicted outcome in 21 of 23 patients in groups 0 and 2. We also observed that of 15 DR blank patients (10 of whom were DR4 blank), none entered remission.

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.

Gold compounds in rheumatic diseases--1

Gold complexes diminish synovitis and improve therapeutic outcome in rheumatoid arthritis, psoriatic arthritis, some forms of juvenile chronic arthritis, and palindromic rheumatism. The decision to treat a patient with a gold compound should not be undertaken lightly. It should be understood by the patient that the commitment to therapy is potentially long-term, that major benefit is not assured, and that there is, approximately, a 50% probability of an adverse reaction which may terminate treatment. Nevertheless, most adverse effects are mild and transient and the probability of good control, even remission, in an otherwise threatening disease, is sufficiently high to justify a therapeutic trial in the majority of patients. Those patients whose rheumatoid arthritis appears to respond to gold may be encouraged to continue long-term therapy with maintenance doses, in view of the evidence of sustained efficacy in most patients and of the declining risk of adverse reactions after the first 12 months.

Gold compounds in rheumatic diseases--2

Though many basic questions on the mechanism of action, dosage schedules, and long-term efficacy remain to be answered, gold therapy still plays a major role in the treatment of rheumatic diseases. Continuous, rather than intermittent, treatment with intramuscularly administered gold compounds is now recommended, though treatment terminations due to side-effects or lack of efficacy are relatively high in the long term. The advent of orally administered gold preparations may herald a new approach to chrysotherapy of rheumatic conditions. However, the toxicity of gold compounds remains high and can be reduced only by the strictest monitoring schedules. Serial blood tests should be performed regularly, and any downward trend in platelet or neutrophil counts should be regarded with suspicion. Early detection of toxicity is likely to prevent the occurrence of severe side-effects.

Effect of heavy metals on human rheumatoid synovial cell proliferation and collagen synthesis

The dose-dependent effects of heavy metals on cell proliferation, collagen synthesis, and non-collagen protein synthesis were studied in early passage cultures of human synovial cells exposed to 1-100 microM concentration of gold, silver, mercury, cadmium or lead for 5 days. The incorporation of [3H]thymidine into trichloroacetic acid insoluble material was inhibited 50% by each of the heavy metals at concentrations between 1 and 10 microM. Gold, lead and mercury (10 microM) decreased the DNA content of the cultures by less than 15%; silver (10 microM) and cadmium (10 microM) resulted in decreased DNA content, which was attributed to cytotoxicity. A dose-dependent inhibition of [3H]proline incorporation into bacterial collagenase resistant (non-collagen) protein was observed after incubation with 10 microM mercury, lead and silver. During incubations with 10 microM gold and cadmium, collagenase resistant protein accumulation increased. All the heavy metals except for gold inhibited collagen accumulation to a greater extent than non-collagen protein accumulation. Gold (10 microM) stimulated the amount of collagen produced per cell, and the percentage of collagen to total protein was increased 50%. The rate of collagen accumulation in medium decreased during incubation with 10 microM silver, mercury, cadmium and lead. The stimulation of collagen synthesis may be a unique property of gold related to the therapeutic indices of gold, compared to other heavy metals, in rheumatoid arthritis.

Mechanisms of action of gold

Since the successful introduction of injectable gold compounds for the treatment of rheumatoid arthritis over 50 years ago, numerous studies on the possible mechanism of action have been performed. This heavy metal has been show to possess a bewildering array of biological effects. Studies using gold performed both in vitro and in vivo can be grouped into anti-microbial, anti-immunologic, anti-inflammatory, anti-enzymatic and other effects. In this survey, we have analyzed these multiple approaches to the study of the mechanism of action of injectable gold preparations and apply the findings to rheumatoid arthritis.

Maintenance chrysotherapy in rheumatoid arthritis: a comparison of 2 dose schedules

Maintenance treatment with chrysotherapy was given to 44 rheumatoid patients after a total of 1.0 g weekly injections of sodium aurothiomalate. 21 patients continued with 50 mg injections every 2 weeks, and 23 patients received the same dose at 4-week intervals. Their progress was followed over 1 year, after which time their clinical improvements were equally well sustained. Toxicity was greater in those patients receiving fortnightly injections. Five patients suffered a relapse after 8 months. These were not related to the frequency of injections nor to the serum gold levels. There appeared to be no advantage in maintenance injections at fortnightly intervals.

Pharmacotherapy of juvenile rheumatoid arthritis

Salicylate is the drug of first choice in the initial treatment of juvenile rheumatoid arthritis. In therapeutic dosage it will adequately control joint symptoms in the majority of patients. For children who do not respond to or are intolerant of salicylate, a change to one of the other nonsteroidal anti-inflammatory agents is appropriate. In progressive polyarthritis unresponsive to the above agents, the addition of gold, antimalarials, or penicillamine is indicated, preferably in that order. Corticosteroid therapy should be reserved for selected patients meeting specific criteria. Pharmacotherapy of juvenile rheumatoid arthritis should always be individualized. For optimal treatment of the whole child it must be combined with both physical and educational measures.

Gold in erythrocytes, whole blood, and plasma during long-term chrysotherapy

The concentrations of gold in erythrocytes, whole blood, cell-rich plasma, and cell-free plasma were investigated in 17 patients with rheumatoid arthritis undergoing long-term chrysotherapy. Gold estimations were performed with a graphite tube atomic absorption spectrophotometer. Significant quantities of gold were found in isolated erythrocytes of 12 patients. There was no correlation between erythrocyte gold and therapeutic response, plasma gold, and gold in whole blood. Nor did gold in whole blood or plasma show any correlation with therapeutic responses and toxic reaction. However, all patients (3) with toxic reactions had a significantly higher gold concentration in the erythrocytes than the patients without toxic reactions. This result indicates that erythrocyte gold estimations could provide a useful warning of impeding toxic reactions.

Remission-inducing drugs in rheumatoid arthritis

The administration of certain drugs to patients with established rheumatoid arthritis frequently results in improvement that is slow to appear but persists for long periods, even after the drug is discontinued. The three main drugs with this effect, whose efficacy and toxicity are reviewed in this paper, are gold salts, D-penicillamine and chloroquine. The cytotoxic agents used to treat rheumatoid arthritis, which likely have nonspecific anti-inflammatory actions and have serious long-term side effects, are also briefly reviewed. A new drug, levamisole, is currently being tested in patients with rheumatoid arthritis. It is suggested that the time for considering the introduction of a remission-inducing drug in patients with progressive rheumatoid arthritis is after an adequate trial of therapy with salicylates or other nonsteroidal anti-inflammatory agents, or both, and before the oral administration of steroids. It is difficult, however, on the basis of rigorous clinical comparisons, to recommend which of the three main remission-inducing drugs should be tried first, although gold salts have been used the most. Patients who have improved with 6 months of chrysotherapy may continue treatment for at least 3 years, during which time the frequency of mucocutaneous and renal toxic effects will steadily decrease. Some aspects of the medical economics of therapy with remission-inducing drugs for rheumatoid arthritis are discussed.

Gold binding to blood cells and serum proteins during chrysotherapy

The binding of gold to peripheral erythrocytes and serum protein fractions was studied during chrysotherapy of 1 to 2 years' duration in 43 patients with rheumatoid arthritis. In 45% of the patients more than 10% of the gold was found to be strongly bound to blood cells. 5--15% of the metal is bound to non-albumin protein fractions at serum gold concentrations larger than 2 microgram/ml. In contrast to the cellular binding of gold the relative binding of gold to non-albumin proteins was inversely proportional to the serum concentrations. Binding to neither blood cells nor to non-albumin protein fractions was found to be correlated with clinical parameters.

Distribution of gold among plasma fractions in rheumatoid patients undergoing chrysotherapy compared with its distribution in plasma incubated with aurothiomalate in vitro

The distribution of gold among the globulin, albumin, and unbound fractions of plasma, obtained either from rheumatoid patients receiving long-term aurothiomalate therapy or from samples incubated with aurothiomalate in vitro, has been investigated. In the rheumatoid patients it has been found that, although the majority of the plasma gold is always bound to albumin, the distribution varies cyclically in phase with the dose schedule. An explanation of these phenomena is provided, based on data obtained from the reaction between aurothiomalate and plasma constituents in vitro.

Neutropenia associated with chrysotherapy for juvenile rheumatoid arthritis

Severe neutropenia, in the absence of generalized bone marrow depression, is a rare complication in adults receiving chrysotherapy for rheumatoid arthritis and has not been described in children. Isolated, severe neutropenia developed in five children with systemic onset JRA while they were receiving gold injections. This potentially fatal complication occurred within eight weeks of beginning therapy in four patients, and after 24 weeks of well-tolerated therapy in the fifth. Leukopenia preceded neutropenia in two children. Localized infection was successfully treated in one child; septicemia was fatal to a second child. Neutropenia resolved within eight to 14 days of its onset in the four survivors; chelation with dimercaprol in one child did not appear to alter the recovery time. It is suggested that a systemic onset of JRA in children less than 6 years of age identifies a higher risk group developing severe neutropenia during chrysotherapy. Cessation of gold therapy upon recognition of a decreasing neutrophil count may prevent or ameliorate a developing neutropenia; careful observation for, and early treatment of, infection may alter its outcome.

Chrysotherapy. Suppression of immunoglobulin synthesis

Forty-four subjects with classic or definite rheumatoid arthritis who were on individualized chrysotherapy were observed for changes in serum protein electrophoresis, immunoglobulins, and circulating lymphocyte counts. By paired variate analysis, significant declines from pretreatment values were recorded for the following--electrophoretic protein fractions: gamma, alpha-1, alpha-2, (P less than 0.05); immunoglobulins: IgM--53% (P less than 0.001), IgG--37% (P less than 0.01), IgA--34% (P less than 0.001). Rheumatoid factor decreased in 29 of 39 subjects, 15 becoming seronegative (P less than 0.001); circulating lymphocytes decreased by 27% (P less than 0.001). The maximal suppressive effect on IgG and IgM was not achieved until the third and fourth years of therapy by sustained weekly administration of gold sodium thiomalate (one year cumulative dosage, mean 2106 mg, range 1065-2,885; greater than or equal to 4 year cumulative dosage, mean 8747 mg, range 5,385-15,160 mg). An immunosuppressive effect is suggested by these results.

Prostaglandin production by macrophages and the effect of anti-inflammatory drugs

1 Macrophages derived from peritoneal cavity inflammatory exudates of guinea-pigs produced substantial amounts of prostaglandin E2-like activity during in vitro culture, so providing the basis for an experimental model of prostaglandin production during inflammatory reactions. 2 Dose-related inhibition of prostaglandin biosynthesis was demonstrated by 16 acidic non-steroidal anti-inflammatory drugs. 3 Seven anti-inflammatory glucocorticosteroid preparations inhibited prostaglandin production in a dose-related manner. The relative potencies of dexamethasone, prednisolone and hydrocortisone were consistent with clinical anti-inflammatory ranking. Cortisone, however, failed to inhibit macrophage prostaglandin production. 4 Three other agents used in the treatment of inflammatory joint diseases were examined. Sodium aurothiomalate inhibited prostaglandin production, although higher concentrations were toxic to macrophages. D-Penicillamine did not affect macrophage prostaglandin production. Colchicine, in contrast, enhanced prostaglandin production at some concentrations. 5 The probable significance of macrophages as a source of prostaglandins, during inflammatory responses, is discussed.

Comparison of gold levels and distribution in guinea pig serum

Serum levels after oral administration of 30 mg/kg of sodium aurothiomalate (Myocrisin), triethylphosphine gold chloride, or triphenylphosphine gold chloride to guinea pigs indicated that all were orally absorbed. However, the serum gold level of triethylphosphine gold chloride was three to four times that of Myocrisin or triphenylphosphine gold chloride and was comparable with the serum level produced when the same dose of Myocrisin was injected intramuscularly. A comparative time-course study between intramuscular administration of Myocrisin and oral administration of triethylphosphine gold chl;ride indicated that during the first 24 hours after intramuscular injection of Myocrisin, a large fraction of the gold was not protein-bound, whereas all detectable gold in serum after oral administration of triethylphosphine gold chloride was protein-bound. Gold levels in the separated protein fractions indicate that the gamma-globulin level after oral administration of triethylphosphine gold chloride is approximately three times higher after 24 hours than with intramuscular Myocrisin.

Gold serum levels in children with juvenile rheumatoid arthritis

Serum gold levels were monitored in 66 children with juvenile rheumatoid arthritis, treated with different i.m. dosage schedules of sodium aurothiomalate (Myocrisin, Pharma Rhodia). The ages of the children varied from 1 to 15 years. Gold serum levels in children were related to the dose of Myocrisin calculated per kg of body weight or per square metre of body surface area. The results of our study indicate that in order to achieve a peak serum level at about 500--600 microgram/100 ml (25--30 micromol/l) with weekly injections, the dose of Myocrisin should be about 0.7 mg/kg, or 20 mg/m2. In order to avoid excessively high gold serum concentrations, the maximum single dose should not exceed 27 mg/m2 of body surface area.

Determination of gold in plasma and plasma fractions by atomic absorption spectrometry and by neutron activation analysis

Three techniques of gold analysis, flame and electrothermal atomic absorption spectrometry and neutron activation analysis, have been compared, using plasma and plasma fractions (derived by gel chromatography) from rheumatoid patients receiving aurothiomalate therapy and from plasma samples incubated with aurothiomalate in vitro. The three methods correlated well in the analysis of gold in whole plasma, but only neutron activation analysis was suitable for the assay of all the plasma fractions. The susceptibility of the two atomic absorption methods to interference by sodium chloride was investigated.

A double-blind trial of high versus conventional dosages of gold salts for rheumatoid arthritis

In a double-blind study, patients were randomly selected for treatment using conventional doses (CD; 50 mg) or high doses (HD; 150 mg) of sodium aurothiomalate given weekly by injection. Twenty-three patients were assigned to the CD group and 24 to the HD group. Neither efficacy nor toxicity correlated with serum gold concentrations. Conventional doses were as efficacious as high doses with respect to both rapidity and degree of response. However, side effects were much more frequent and severe in the HD group. Thus there is no reason to recommend a 150 mg weekly dosage regimen.

Comparison of two dosage schedules of gold salts in the treatment of rheumatoid arthritis. Relationship of serum gold levels to therapeutic response

Two doses of gold sodium thiomalate were compared for their effect on rheumatoid arthritis. Thirty-seven patients with active disease for longer than 6 months were treated with 25 mg of gold sodium thiomalate for an average of 29.6 weeks, then at biweekly or monthly intervals to complete 2 years of treatment. Thirty-eight patients were given more than twice as much gold salt at the same intervals on a flexible dose schedule that produced serum gold levels which averaged 332 microgram/dl during the weekly injection phase. No differences were observed in the therapeutic responses of the two groups. Therefore the minimal dose of gold sodium thiomalate required to induce a response in rheumatoid arthritis is 25 mg or less per week. Serum gold levels in the steady state varied between 95 and 386 microgram/dl and were not related to response. Serum half-life for gold was calculated for patients who had an excellent response and for those who were treatment failures. The rate at which gold disappeared from serum was not related to therapeutic responses.

Gold compounds in rheumatoid arthritis. Report of a symposium

A vast accumulation of clinical experience and controlled studies justifies the use of gold compounds in selected cases of rheumatoid arthritis. The striking therapeutical efficacy observed in some patients has stimulated active research to clarify the pharmacokinetics and mechanisms of action of gold compounds. Based on this knowledge, the possibility of selecting gold-responsive patients may be enhanced, and the frequency of adverse reactions decreased. Liberal indications and inexperience in administration and control have given gold therapy mixed reputation. A symposium in Umeå, Sweden, summarized present knowledge and current concepts among Scandinavian rheumatologists on the rational use of gold compounds.

Chrysotherapy. A prospective study

A 4-year prospective clinical study of chrysotherapy was designed to reexamine old beliefs and traditions, and to test potentially new approaches to chrysotherapy. The standard weekly dosage of 50 mg was compared to that based on 1 mg/kg body weight; no significant differences were found. The rapidly absorbed aqueous thiomalate was compared to the slowly absorbed oil repository thioglucose; the latter produced significantly less side effects and an appreciably higher percentage of improvement. Almost half (43%) of nonresponders on standard regimen had a satisfactory clinical response at higher dosage levels without increase in toxicity. Some of these findings vary so much with traditional beliefs and practices that the authors urge caution in their interpretation. But generally speaking these problems are technical and do not detract from the conviction that chrysotherapy is valuable and comparatively safe in the management of rheumatoid arthritis and that it deserves more widespread application in clinical practice.

Auranofin. New oral gold compound for treatment of rheumatoid arthritis

Eight patients with rheumatoid arthritis were treated with SK & F D-39162 (auranofin), a new oral gold compound which was effective in suppressing adjuvant-induced arthritis in rats. Clinical and humoral parameters were studied during a 3-month period of drug administration followed by a 3-month period under placebo. The drug was absorbed, well tolerated, and its action was manifested by a drop in the mean IgG blood levels in the third week of treatment accompanied by clinical improvement after 5 weeks of oral gold intake. Together with IgG changes, an increase of the albumin ratio was observed, as well as a decrease of alpha2-globulin and rheumatoid factor titres. From a total number of 60 swollen joints found initially in the 8 patients only 17 were swollen at week 12 and 9 at week 15. Although the number of patients treated was too small to allow definite conclusions, a follow-up study under placebo of clinical and laboratory changes in the same patients during another 3-month period showed that IgG serum levels rapidly reverted preceding a flare up of disease activity after withdrawal of the drug. This confirmed a direct role in cause-effect relation played by the new oral gold compound.