In rheumatoid arthritis the most commonly used gold salts are sodium aurothiomalate and aurothioglucose (3). There is some reason to believe that adverse effects are less frequent with the suspensions (of aurothioglu-cose or aurothiosulfate) than with the more rapidly absorbed solution (of sodium gold thiomalate) (SEDA-16, 233) (4).
Whereas gold was previously regarded as one of the most toxic drugs in the pharmacopeia, many authors now share the view that its adverse effects can to an important extent be contained by individually adapted dosage regimens and careful monitoring. However, it is not strictly possible to predict the nature or timing of the complications that an individual may experience, and it has to be borne in mind that some reactions are immunological (SEDA-21, 236). The prevalence of adverse gold reactions seems to be similar in patients given 25 or 50 mg of gold weekly (SED-12, 520) (5). Some studies have suggested that the frequency of mucocutaneous and renal adverse reactions may be higher in the initial months of treatment. In one series of patients receiving gold sodium thiomalate, a plateau in the cumulative incidence of withdrawals due to rash was reached only after 40 months (45% of all patients), while withdrawals due to proteinuria reached a plateau after 18 months (l5%) (6). Hematological complications can occur at any stage.
It is widely considered that the patients who are most likely to develop adverse reactions to gold salts are those who react most favorably. In the past, many rheumatolo-gists intensified treatment with high doses of gold salts until a skin eruption occurred, only then seeking to reduce to a maintenance dosage.
After withdrawal due to adverse reactions, treatment with gold compounds can be cautiously reintroduced without the previous adverse effects necessarily reappearing. However, clearly one will not take this course if life-threatening reactions have occurred. It should always be borne in mind that many adverse reactions allegedly due to chrysotherapy may have other causes, particularly in the case of skin reactions. Most patients have been or are using other drugs at the same time. The concomitant use of penicillamine can be particularly confusing, since its pattern of adverse effects closely resembles that produced by gold.
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