Gold (Auranofin, Aurothioglucose, Aurothiomalate)

Rheumatoid arthritis treatment for patients without sufficient response to initial treatment with NSAIDs, steroids, or other DMARDs.

May have efficacy in pemphigus vulgaris, psoriatic arthritis, and palindromic rheumatism but lacks trials is and rarely used due to availability of other therapies.

Availability of other DMARDs, such as biologic TNF inhibitors and methotrexate, has decreased the use of gold.

IM gold associated with higher dropout rates due to side effects when compared to other DMARDs (up to 19% in one study).

Cutaneous reactions range from erythema and pruritus (30% of pts) to exfoliative dermatitis.

Mucous membrane lesions (20% of pts), including stomatitis, pharyngitis, gastritis, and colitis.

Dermal deposits and chrysiasis (gray-to-blue pigmentation of sun-exposed skin) are possible with large cumulative doses. Effect on transcutaneous Hgb saturation measurement is unknown. Some pts are noted to have corneal deposits.

Allergic (5% of pts): Anaphylactoid and nitritoid reactions, with transient flushing, nausea, hypotension, dizziness, and diaphoresis (especially seen in pts also taking ACE inhibitors).

GI (5% of pts): Diarrhea (common in pts taking the oral formulation auranofin), enterocolitis, jaundice and hepatic toxicity (from cholestasis), transaminitis, pancreatitis, and metallic taste.

Renal: Proteinuria (10–15%, usually resolves with cessation of treatment), renal tubule deposition, acute renal failure, and nephrotic syndrome. Use caution in pts with decreased renal function due to delayed elimination.

Pulmonary infiltrates and interstitial pulmonary disease are rare and usually resolve with cessation of treatment; difficult to differentiate from underlying RA pulm fibrosis.

Hematologic: Thrombocytopenia (<5%, usually develops in first 6 mo, immune-mediated attack on bone marrow reverses with cessation of treatment), leukopenia (2%), eosinophilia, bone marrow suppression, rare progression to aplastic anemia. This can be avoided in pts given antimalarials, phenylbutazone, or oxyphenbutazone because of cumulative bone marrow suppression.

Neurologic: Cranial nerve palsies, encephalitis, Guillain-Barré-like syndrome. Peripheral neuropathy (<1%—painful paresthesias progressing to asymmetric weakness, may be preceded by fever/rash; direct toxic effect vs. hypersensitivity reaction).

Not usually administered to pregnant pts but limited published data are available.

Use caution in the elderly (due to underlying renal insufficiency and bone-marrow suppression).