Intramuscular gold is the traditional #1 drug in RA, with over 50 years of clinical use. There is little risk of an unanticipated surprise with gold, and it has a reasonably sustained effect over the long term. The major disadvantages include the need to visit the doctor each week, and the long time it may take to begin to work (12 to 20 weeks).
To make sure the patient isn’t sensitive to gold, two small test doses of aurothiomalate are given, one week apart. After that, the regular dose (50 milligrams) is given once a week. The practice in the past was to do this, once a week, until 1,000 milligrams had been given, and some doctors still do this. If the patient is no better, they then try another drug. The problem is that some patients may show a great deal of improvement long before five months (the time needed to give 1,000 milligrams) are up and others will need quite a bit longer.
Most rheumatologists will start to space the doses out, at first to every second week, and then to every third, when they feel the maximum benefit has been reached. It’s possible, but unusual, to be able to space the doses out to once a month. Once a patient is on a “maintenance schedule,” it is continued indefinitely (for years), even if the arthritis seems to have disappeared. If the arthritis flares up (it very often does), it is important to realize that the gold hasn’t lost its effect. It simply needs to be given more often.
Because the blood and urine side effects may turn up at any time, the patient should have a blood and urine test each time an injection is given, although if the patient has been safely on gold for several years, this is sometimes spaced out to every second injection.
Side Effects of Gold Injections
Common to Occasional
- Sore mouth and itchy skin, often the first sign of side effects. If gold is continued on the same schedule, mouth ulceration and more extensive skin rash may result. The dose should be withheld for a week or two, until the symptoms subside. Injections can then be resumed, either with a reduced dose or with an increased interval between shots.
- Flare-up of arthritis symptoms, or facial “flushing” and headache, following the weekly injection. This is often controlled by the use of prednisone, given only on the day of the injection. There is no risk of steroid side effects with this.
- Thrombocytopenia (a drop in the level of platelets in the blood). If this level falls below a certain point, there is a risk of bruising or even uncontrolled bleeding. The drop is due to an allergic reaction to the gold, and most often reverses if the drug is stopped. Sometimes steroids are used to treat the allergic reaction and speed recovery.
- Proteinuria (the “leakage” of a protein (albumin) into the urine in abnormally high amounts). Normally the kidney filter is very fine, but an allergic reaction to gold may cause the kidney “pores” to enlarge and allow the large albumin molecules to escape. Proteinuria is very much like thrombocytopenia. It clears up when gold is stopped, but this may take some time and may require corticosteroids.
- A drop in the white blood cell count, or aplastic anemia (where the bone marrow stops production of red and white blood cells, as well as platelets). These complications may be fatal.
- Colitis, with severe diarrhea
- Gold “pneumonia”
- Severe generalized skin rash