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

Cholestatic hepatitis caused by acute gold potassium cyanide poisoning

INTRODUCTION

Poisoning after oral ingestion of gold potassium cyanide is rarely reported. A case of suicidal ingestion of gold potassium cyanide (potassium dicyanoaurate; CAS# 13967-50-5) is described.

CASE REPORT

A 27-year-old man attempted suicide by ingesting 5 mL gold potassium cyanide solution. He developed vomiting, hyperamylasemia, and hepatic dysfunction. Cyanide poisoning was not detected but acute gold toxicity was noted. Pathologic findings of the liver showed centrilobular cholestasis with eosinophilic degeneration. The whole blood and serum gold were 4361 and 6011 microg/L, respectively, and the 24-hour urine gold was 429 microg/d in samples obtained on day 4.

CONCLUSION

Gold-induced hepatotoxicity has been seen infrequently in patients receiving gold therapy. Reported agents include sodium aurothiomalate, sodium aurothiopropranol sulfonate, aurothioglucose, aurothiopolypeptide (Auro-detoxin), auric sulfide, and gold thiosulfate, our report adds gold potassium cyanide.

Thiol-reactive metal compounds inhibit NF-kappa B activation by blocking I kappa B kinase

Gold compounds are used in the treatment of rheumatoid arthritis. NF-kappa B is a transcription factor implicated in the expression of many inflammatory genes. NF-kappa B is activated by signal-induced phosphorylation and subsequent degradation of inhibitory I kappa B (inhibitory protein that dissociates from NF-kappa B) proteins, and a multisubunit I kappa B kinase (IKK) has been identified previously. We tested the effect of various gold compounds on the activation of NF-kappa B and IKK in LPS-stimulated RAW 264.7 mouse macrophages. A lipophilic gold compound, auranofin, suppressed the LPS-induced increase of nuclear kappa B-binding activity, degradation of I kappa B proteins, and IKK activation. Auranofin also blocked IKK activation induced by TNF and PMA/ionomycin, suggesting that the target of auranofin action is common among these diverse signal pathways. In vitro IKK activity was suppressed by addition of hydrophilic gold compounds, such as aurothiomalate, aurothioglucose, and AuCl3. Other thiol-reactive metal ions such as zinc and copper also inhibited IKK activity in vitro, and induction of IKK in LPS-stimulated macrophages. In vitro IKK activity required the presence of reducing agent and was blocked by addition of thiol group-reactive agents. Two catalytic subunits of IKK complex, IKK alpha and IKK beta, were both inhibited by these thiol-modifying agents, suggesting the presence of a cysteine sulfhydryl group in these subunits, which is critical for enzyme activity. The antiinflammatory activity of gold compounds in the treatment of rheumatoid arthritis may depend on modification of this thiol group by gold.

The mechanisms of action of disease-modifying antirheumatic drugs: a review with emphasis on macrophage signal transduction and the induction of proinflammatory cytokines

1. Rheumatoid arthritis (RA) is probably the most common source of treatable disability. A major problem in modern rheumatology is that the mechanism(s) of action of the currently used disease-modifying antirheumatic drugs (DMARDs) remain unclear. Many of these drugs entered rheumatology mainly through clinical intuition and have been used for decades. 2. The former T-cell-centered paradigm of rheumatoid inflammation has given way to a model of inflammation highlighting the macrophage and its proinflammatory cytokines. In particular, tumor necrosis factor alpha (TNF-alpha) has gained prominence as a central proinflammatory mediator in RA, and antibodies against TNF-alpha have been successfully used in patients with RA. 3. This review will summarize the recent advances in determining the mechanisms of action of the currently used DMARDs, with particular emphasis on their effects on the induction of TNF-alpha and interleukin 1 (IL-1) in mononuclear phagocytes. Although some DMARDs, such as auranofin, antimalarials and tenidap, act as inhibitors of the induction of these cytokines in monocytes or macrophages or both, other drugs, such as methotrexate, D-penicillamine and aurothiomalate, do not seem to affect either TNF-alpha or IL-1. 4. The drugs' effects on proinflammatory cytokine induction are correlated to those on other macrophage responses.

Lichenoid dermatitis after consumption of gold-containing liquor

Medicinal gold has a well-known side effect profile that includes mucocutaneous eruptions. We describe three patients with a pruritic dermatitis that began after consumption of a gold-containing alcoholic beverage. Blood and urine gold levels, chemistry panels, hepatitis screens, skin biopsies, and patch tests were performed. The gold-containing liquor was analyzed for the presence and quantity of gold. The liquor consumed by all of the patients was a cinnamon schnapps with free-floating gold-colored flakes. Gold is present in the liquid portion of this liquor and in the solid flakes. Elevated levels of gold in the urine and blood were present in one patient 3 months after last drinking this beverage. Another patient had a positive patch test to gold sodium thiosulfate. All patients experienced improvement of their dermatitis after they stopped drinking the gold-containing liquor.

The effect of second-line antirheumatic drugs on interleukin-8 mRNA synthesis and protein secretion in human endothelial cells

Interactions between interleukin 8 (IL-8) and endothelial cells play an important role in the emigration of mononuclear cells from the blood into areas of inflammation. We examined the ability of specific second-line antirheumatic drugs to regulate (IL-8) gene expression and protein secretion in interleukin 1 (IL-1) stimulated human umbilical vein endothelial cells and peripheral blood mononuclear cells. The drugs sodium aurothiomalate, D-penicillamine and sulphasalazine were all able to modulate IL-8 mRNA synthesis in and protein secretion from endothelial cells. A bimodal effect was observed: at low concentrations IL-8 was suppressed, whereas higher concentrations resulted in an increased IL-8 production. In endothelial cells, treatment with hydrocortisone led to a linear suppression of IL-8 production in concentrations ranging from 0.5 micrograms/ml up to 500 micrograms/ml. Sulphapyridine, auranofin, hydroxychloroquine and methotrexate, had no effect on IL-8 secretion in endothelial cells. By contrast, 5-aminosalicylic acid induced a threefold increase in the IL-8 release. In peripheral blood mononuclear cells it was only possible to suppress the IL-8 production by hydrocortisone treatment. These results indicate that suppression of IL-8 production in endothelial cells could be an important factor in the mode of action for a number of second-line antirheumatic drugs.

Effect of sodium aurothiomalate on carrageenan induced inflammation of the air pouch in mice

Acute inflammation was induced by injecting carrageenan into a 6 day old air pouch in mice. Sodium aurothiomalate was then given twice to each of three groups of mice via different routes. It was found that the mice injected intravenously with sodium aurothiomalate showed the most striking reduction in the number of exudate leucocytes in the inflammatory cavity, although the amount of gold found in their inflamed pouch lining tissue was the least. The amount of gold in plasma was highest in the mice injected intravenously with sodium aurothiomalate and the least amount of gold was found in the mice injected directly into the air pouch with sodium aurothiomalate. The amount of gold in the inflamed pouch lining tissue reached its peak at 24 hours after injection and a significant decrease of exudate leucocytes was only seen 24 and 72 hours after injection. The amount of gold in the exudate fluid was negligible at all the times studied. No significant difference was noted in the degree of inflammatory suppression when increasing doses of sodium aurothiomalate were injected into the air pouch. These findings show that there is no direct correlation between the gold concentration in the inflamed tissue and suppression of the inflammatory reactions in the cavity. Chemotactic and phagocytic analysis of leucocytes in the exudate showed that there was a significant suppression of the neutrophil activities in all the mice treated with sodium aurothiomalate. It is therefore concluded that the significant reduction in the number of exudate leucocytes at the carrageenan induced inflammatory site after treatment with sodium aurothiomalate is most likely due to the direct action of gold on the functional activities of circulating neutrophils.

The effect of gold sodium thiomalate and auranofin on lipopolysaccharide-induced interleukin-1 production by blood monocytes in vitro: variation in healthy subjects and patients with arthritis

The anti-rheumatic gold compounds gold sodium thiomalate (GST) and auranofin (AF) have variable and often unpredictable effects in patients treated for arthritis. As inhibition of interleukin-1 (IL-1) production may be an important effect of these drugs, we investigated their effect on IL-1 production by lipopolysaccharide (LPS) stimulated monocytes in a serum-free, non-adherent culture system. A bi-modal effect was observed: low concentrations (GST 10-250 ng/ml and AF 1-100 ng/ml) potentiated IL-1 production, and higher concentrations (GST 200-1000 ng/ml and AF10-500 ng/ml) inhibited it. This bi-modal effect was observed for both secreted and cell-associated IL-1 activity with the exception that GST failed to inhibit cell-associated IL-1 generation. The potentiating effect was dependent on the continuous presence of gold for at least the first few hours after LPS stimulation. The inhibitory effect of GST was dependent on its presence after LPS stimulation while that of AF was evident even if cells were pretreated with AF and washed before exposure to LPS. There was considerable individual variation in IL-1 production in response to LPS as well as in the effects of gold on cells from both healthy individuals and patients with arthritis. There was also some overlap in the range of concentrations of gold that potentiated and inhibited IL-1 production, and there was relative insensitivity to the inhibitory effects of gold in certain individuals. These results may explain some of the variability in the response of patients to chrysotherapy and support further studies to see if these in vitro effects might predict clinical response to gold.

Treatment of rheumatoid arthritis

The management of the rheumatoid patient involves the considered use of pharmacologic agents as therapies to induce symptomatic relief and to reduce disease activity. Aspirin and nonsteroidal antiinflammatory drugs are used initially to lessen the degree of pain and swelling associated with the inflammatory disease process. The aggressive institution of second-line therapy, previously known as disease-modifying antiinflammatory rheumatic drugs, is advocated to modify the disease course itself. These second-line treatments include antimalarials, gold salts, methotrexate, d-penicillamine, and azathioprine. Randomized placebo controlled trials have demonstrated the efficacy of these compounds in this illness. Improvement in standard parameters of disease activity (number of painful and swollen joints, duration of morning stiffness, erythrocyte sedimentation rate) can be related to the therapeutic value of second-line agents. Whether they modify radiographic progression is under rigorous study. Newer therapies under research investigation include sulfasalazine, cyclosporin A, and combination therapy.

Electrochemical behavior and polarographic determination of auronofin

Auronofin in a 50% ethanol:water solution yields, on the dropping mercury electrode, a reduction wave whose E1/2 is a function of pH in the 2 less than pH less than 9 range (E1/2 = -0.036-0.054 pH), and acquires a constant value above pH 9 (E1/2 = -0.50 V, versus saturated calomel electrode). The influence of the variables which affect the reduction process of auronofin in tripotassium phosphate medium was studied. The electrochemical process is reversible and diffusion controlled. Coulometry showed that one electron is involved in the reduction of the drug. Analytical methods are proposed for the determination of auronofin at micromolar levels by DC and DP polarography, with relative standard deviations of 3.2 and 2.4%, respectively.

Inhibition of alveolar macrophage 5-lipoxygenase metabolism by auranofin

We have examined the effect of the oral gold compound auranofin (AF) on calcium ionophore A23187-induced arachidonic acid metabolism in the rat alveolar macrophage. Both reverse-phase high performance liquid chromatographic and radioimmunoassay analyses revealed that AF dose-dependently inhibited leukotriene B4 and 5-hydroxyeicosatetraenoic acid synthesis in a parallel fashion with an IC50 approximately 4.3 micrograms/ml. At the same time, AF augmented A23187-induced arachidonate release and cyclooxygenase metabolism. A possible mechanism for the inhibition of 5-lipoxygenase was suggested by the capacity of AF to dose-dependently deplete ATP (IC50 approximately 5.9 micrograms/ml), a cofactor for 5-lipoxygenase. These data indicate that, at therapeutic concentrations, AF acts in vitro as a selective inhibitor of macrophage 5-lipoxygenase metabolism. This likely represents an important mechanism of action of AF in chronic inflammatory disorders.

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.

Rabbit articular chondrocytes: an in vitro model for studying the effect of sodium aurothiopropanol sulfonate on proliferation kinetics, type II collagen phenotype and mitochondrial activity

Despite the benefits of chrysotherapy the responsible mechanism of action of gold compounds remains unclear. At a concentration of 5 x 10(-4) M, sodium aurothiopropanol sulfonate (SAS) modified the in vitro proliferation kinetics of articular chondrocytes by reducing growth, viability and plating efficiency. Flow cytometry analysis, using propidium iodide DNA staining, revealed slight but significant cell arrest in G2+M which, in fact, represents an increase in the proportion of binucleate cells. SAS did not induce any variations in chondrocyte phenotype stability as far as the biosynthesis of type II collagen was concerned, and no appreciable changes in overall mitochondrial activity reflected by rhodamine 123 incorporation.

Effect of auranofin and sodium aurothiomalate on interleukin-1 production from human monocytes in vitro

The continuous presence of Auranofin (AF), 1.0 microgram/ml and above, or sodium aurothiomalate (GST), 2.0 micrograms/ml and above, inhibited the phytohaemagglutinin-induced proliferation of monocyte-depleted mononuclear cells. Preincubation of monocytes (M phi) with AF, 1.0 microgram/ml, caused a minor increase in the co-stimulatory effect of LPS-induced M phi-culture supernatants, whereas preincubation with AF 2.5 micrograms/ml and above resulted in a dose-dependent decrease in production of the co-stimulatory factor--probably interleukin-1 (IL-1). This inhibition is not due to decreased M phi viability, production of suppressive substances, or drug interference with the IL-1 test assays. A similar preincubation with GST up to 100 micrograms/ml had no effect on IL-1 production, nor did preincubation with thioglucopyranose, triethylphosphine or chloroauric acid, the three molecular sub-components of AF. The inhibitory effect of AF on the production of IL-1--as well as other co-stimulatory monokines--and on lymphocyte proliferation might explain the anti-inflammatory and disease-modifying effect of the drug.

Gold colitis induced by auranofin treatment of rheumatoid arthritis: case report and review of the literature

A case of ulcerative colitis occurred during treatment of rheumatoid arthritis with the new oral gold preparation auranofin after a cumulative dose of 2160 mg. A barium enema showed loss of mucosal pattern and a rectal biopsy disclosed deep erosions, mucosal inflammation, and crypt abscesses. Precipitates of gold were seen in the periglandular stroma. On electron microscopy the gold deposits seemed to be identical to granules described in gold nephropathy. As the extrapolated serum gold level was within the normal range at the onset of the complication, the morphological findings suggested a local toxicity of the drug. The patient recovered within 14 days of withdrawal of auranofin and the start of therapy with sulphasalazine and steroids. A review of the published work shows that the previously reported mortality in gold colitis of 40% has decreased in recent years. The causes of this decrease may be both the earlier diagnosis of gold colitis and the improved intensive care of its severe complications.

Differential inhibitory effects of auranofin on leukotriene B4 and leukotriene C4 formation by human polymorphonuclear leukocytes

Auranofin (AF) is a newly introduced oral gold compound having antirheumatic properties, and its efficacy in the treatment of bronchial asthma is now under investigation. In this study, we examined the effects of AF on leukotriene (LT) formation by human polymorphonuclear leukocytes (PMNs) stimulated with the calcium ionophore A23187. AF inhibited LTC4 formation in a dose-dependent manner with an IC50 (concentration required to produce 50% inhibition of control) of 3.2 microM. In contrast, LTB4 formation was not prevented by AF at concentrations up to 6 microM, but it was reduced to 59 +/- 4% (mean +/- SE, N = 3) of control by an 8 microM concentration. As a next step, we explored the mechanisms of the differential inhibitory effects of AF using cell-free systems. When arachidonic acid (AA) and reduced glutathione (GSH) were used as substrates, AF inhibited LTC4 synthesis more effectively (IC50 = 14 microM) than LTB4 synthesis (IC50 = 100 microM). However, LTB4 and LTC4 syntheses from LTA4 were affected only slightly by AF within the concentrations tested (3-100 microM). These results in the cell-free systems indicate that the inhibition of LT formation was caused by a reduction of LTA4 synthesis and that the differential inhibitory effects can be ascribed to the higher Km value of glutathione S-transferase for LTA4 than that of LTA4 hydrolase in PMNs. In accordance with this hypothesis, LTC4 synthesis was more dependent than LTB4 synthesis on LTA4 concentrations within 25-100 microM, and AA-861, a 5-lipoxygenase inhibitor, caused similar differential inhibitory effects on the formation of LTs by intact PMNs. The inhibitory effect of AF on LT formation at physiological concentrations may play some role in the efficacy of this drug.

Plasma hydroxychloroquine concentrations and efficacy in rheumatoid arthritis

Plasma levels of hydroxychloroquine (HCQ) and its metabolites were measured, by high performance liquid chromatography, in 37 rheumatoid arthritis patients who could be clearly distinguished as responders (n = 28) or nonresponders (n = 9) to HCQ, 400 mg/day. Efficacy in both groups was determined by the patients' erythrocyte sedimentation rates, joint counts, morning stiffness, global assessments, concurrent drug therapies, and grip strength. The response rate was 76%. Responders had a mean HCQ level of 213 ng/ml, versus 306 in nonresponders (P less than 0.05). The mean level of HCQ plus total metabolites in responders was 363 ng/ml, versus 554 in nonresponders (P less than 0.01). We conclude that monitoring plasma HCQ levels is unlikely to be helpful in individualizing effective drug dosage.

Gold therapy and its indications in dermatology. A review

Gold compounds have long been known as therapeutic agents and have been used extensively in the treatment of rheumatoid arthritis. Their mechanisms of action in vivo, however, remain unclear. In comparison to parenteral gold, the pharmacokinetics of a newly available oral compound, auranofin, differ greatly. Auranofin also appears to have specific immunomodulatory actions and to be associated with fewer and milder toxic effects. The role of chrysotherapy in dermatology has been reemphasized recently. It may be used as an adjuvant in pemphigus or other steroid-responsive diseases to help control disease activity and to taper or eliminate corticosteroid therapy more rapidly. Reports on the use of gold in dermatology are otherwise limited. They include one case of epidermolysis bullosa acquisita and psoriatic arthritis. The benefits of gold treatment have to be weighed against the risks inherent in its adverse reactions, some of which are serious and unpredictable.