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Serum gold determinations.

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We conclude that the hypouricemia associated with therapeutic serum salicylate
levels makes the automated serum uric acid
determination a useful guide to the adequacy of salicylate therapy in patients with
RA.
H. WALTER EMORI, MD
Lorna Linda University School of Medicine
Lorna Linda, California
G, DAVID CHAMPION, MD
St. Vincent’s Hospital
Sydney, Australia
RODNEY BLUESTONE, MB
Wadsworth V A Hospital
Los Angeles, California
HAROLD E. PAULUS, MD
UCLA School of Medicine
Los Angeles, California
REFERENCES
1, American Rheumatism Association: Rheuma-
2.
3.
4.
5.
tism and arthritis: Review of American and
English literature of recent years. Ann Intern
Med 50:366, 1959
Koch-Weser J: Serum drug concentrations as
therapeutic guides. N Engl J Med 287:227,
1972
Bittner D, Hall S , McCleary M: A method
for determination of uric acid using the
cupricphenanthroline indicator system. Am
J Clin Pathol40:423, 1963
Stevenson GW: Rapid ultraviolet spetrophotometric determination of salicylate in blood.
Anal Chem 32:1522-1525, 1960
Greene ML, Marcus R. Aurbach GD, et al:
Hypouricemia due to isolated renal tubular
defect. Dalmation dog mutation in man. Am
J Med 53:361, I972
Serum Gold Determinations
T o the Editor:
T h e article by Gottlieb et a1 in ARTHRITIS
RHEUM 17: 171-183, March-April 1974, contains some conclusions about the value of
serum gold determinations which we think
need discussion and comment. Dr. Gottlieb
is a long-time friend of ours. We have a
high regard for his research work and for
his ability as a clinical rheumatologist. The
work reported in his article may indeed
eventually point the way to better chrysotherapy by the determination of whole
blood radiogold disappearance curves as
recommended in his article.
However, we feel that clinicians should
keep an open mind about the value of serum gold levels drawn 1 week after the
administration of maintenance doses of
gold. We have found such serum goid levels to be a very real and practical help to
our patients when obtained as recommended by Lorber et al in ARTHRITIS RHEUM
16~557-558,July-August, 1973.
I n our private practice, we have at least
300 patients under treatment with gold at
all times. From 1971 to 1973 we obtained
serum gold levels at the time the next maintenance dose of gold was due, which varied
from 1 to 4 weeks after the preceding dose
of gold. Serum gold levels obtained at this
time and done in commercial laboratories
showed only slight correlation with clinical
response with one important exception. We
had 4 patients who appeared to have an
excellent clinical response to gold therapy.
They all had low serum gold levels and
persistently high rheumatoid factor titres
above 1:2500. The stress of an intercurrent
infection was followed by an extremely severe and prolonged exacerbation of the
rheumatoid arthritis causing partial or total
disability for the next 3 to 12 months. This
experience was in agreement with a portion
of the presentation by Dr. Lorber (reference
above) at the ARA annual meeting in June
1973. We modified our chrysotherapy in
accordance with the recommendations of
Dr. Lorber. We also had our serum gold
determinations done in Dr. Lorber’s labo-
Arthritis and Rheumatism, Vol. 17, No. 6 (November-December 1974)
1059
ratory. Results from his laboratory appear
to be much less subject to the erratic errors
we had found in the work of two commercial laboratories.
We have now had serum gold determinations performed by Dr. Lorber, obtained 1
week after the maintenance dose of gold in
over 150 patients, to guide our maintenance chrysotherapy. In 36 patients with
low serum gold levels, the interval between
doses of gold was shortened and/or the
dose of gold was increased until the serum
gold level reached 300 pg%. No toxicity to
gold occurred in any of these 36 patients.
We have not had a serious relapse in a
single patient since we have been following
Dr. Lorber’s recommendations. Furthermore, objective evaluation of response shows
that the disease was definitely better controlled in most of these 36 patients. T h e
parameters used for evaluation were as
follows:
Westergren ESR
Grip Strength
Duration of Morning Stiffness
Daiiy Consumption of Aspirin
Ring Sizes of all 10 fingers
Joint Tenderness
Range of Joint Motion
Rheumatoid Factor Titre
X-rays of Hands Taken Every 6 Months
When the work of Gottlieb is carefully
compared with the work of Lorber, there
is not as much discrepancy between their
results as there appears to be. In Lorber’s
series, 32 patients were randomly assigned
to either group A, which received the conventional fixed dose schedule of gold with
maintenance injections gradually stretched
out to every 4 weeks, or to group B, which
received weekly injections with a dose adjusted to keep the serum gold level at 300
pgy0 one week after the injection. At the
end of 12 months, the clinical response in
1060
group B was significantly superior to group
A. All relapses had occurred in patients in
group A. However, at the end of 6 months
of treatment there was no difference between group A and group B. Since the work
of Gottlieb covered only the first 6 months
of therapy, his results are not really in
disagreement with the findings of Lorber.
Neither Lorber nor Gottlieb found any correlation between serum gold levels and clinical response during the first 6 months of
gold therapy. Our results agree with these
observations.
Our observations lead us to believe that
a correlation exists between serum gold level and clinical response but that this does
not manifest itself until sometime after the
first 6 months of therapy and may require
24 months of therapy in order to be clearly
apparent. Furthermore, the correlation may
not be present frequently enough to be
statistically apparent in a small number of
patients such as a group of 18 studied by
Gottlieb. Nevertheless, the correlation may
be of extreme importance to many individual patients on long term chrysotherapy.
PAUL YOUNG,
MD
THOMAS E RARDIN,
MD
Asheville, N C
Long-Term Side Effects of Azathioprine
T o the Editor:
We appreciate Dr. Decker’s (Arthritis
Rheum 16:776,1973) concern regarding the
real and potential long-term side effects of
azathioprine, amply documented in a spate
of recent articles (1-5). As he implies, in
this era of heightened consumer awareness,
there is some obligation on the part of the
physician to provide the patient with pertinent information regarding the efficacy
and toxicity of the drug.
Arthritis and Rheumatism, Vol. 17, No. 6 (November-December 1974)
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