HLA system and side effects of gold salts and D-penicillamine treatment of rheumatoid arthritis

HLA-A33/B44/DR6 is highly related to intrahepatic cholestasis induced by tiopronin

In order to elucidate the immunogenetic predisposition of tiopronin (mercaptopropionylglycine)-induced intrahepatic cholestasis, human leukocyte antigen (HLA) was analyzed in patients with tiopronin-induced liver injury. HLA-A, -B, -C, and -DR loci of 14 patients (10 males and 4 females) with tiopronin-induced liver injury were compared with those of control subjects. The mean duration of tiopronin administration was 26 days and that of jaundice was 4.5 months. The elevation of biliary enzymes lasted from 2 months to up to 10 years. Most of the cases manifested intrahepatic cholestasis on liver biopsy. Lymphocyte transformation test with tiopronin was positive in 6 of 8 (75%) tested cases. Thirteen patients (92.9%) had HLA-A33, 10 (71.4%) had B44, and 9 (64.3%) patients had DR6. These are statistically higher in the patients with tiopronin-induced cholestasis than in the general population. Ten of those with tiopronin-induced liver dysfunction (71.4%) had A33/B44 and 8 (57.1%) had A33/B44/DR6 in their haplotype. In conclusion, long-lasting tiopronin-induced intrahepatic-cholestasis is highly linked to specific HLA-A33, -B44 and -DR6.

Metals and kidney autoimmunity

The causes of autoimmune responses leading to human kidney pathology remain unknown. However, environmental agents such as microorganisms and/or xenobiotics are good candidates for that role. Metals, either present in the environment or administered for therapeutic reasons, are prototypical xenobiotics that cause decreases or enhancements of immune responses. In particular, exposure to gold and mercury may result in autoimmune responses to various self-antigens as well as autoimmune disease of the kidney and other tissues. Gold compounds, currently used in the treatment of patients with progressive polyarticular rheumatoid arthritis, can cause a nephrotic syndrome. Similarly, an immune-mediated membranous nephropathy frequently occurred when drugs containing mercury were commonly used. Recent epidemiologic studies have shown that occupational exposure to mercury does not usually result in autoimmunity. However, mercury induces antinuclear antibodies, sclerodermalike disease, lichen planus, or membranous nephropathy in some individuals. Laboratory investigations have confirmed that the administration of gold or mercury to experimental animals leads to autoimmune disease quite similar to that observed in human subjects exposed to these metals. In addition, studies of inbred mice and rats have revealed that a few strains are susceptible to the autoimmune effects of gold and mercury, whereas the majority of inbred strains are resistant. These findings have emphasized the importance of genetic (immunogenetic and pharmacogenetic) factors in the induction of metal-associated autoimmunity. (italic)In vitro(/italic) and (italic)in vivo(/italic) research of autoimmune disease caused by mercury and gold has already yielded valuable information and answered a number of important questions. At the same time it has raised new issues about possible immunostimulatory or immunosuppressive mechanisms of xenobiotic activity. Thus it is evident that investigations of metal-induced renal autoimmunity have the potential to produce new knowledge with relevance to autoimmune disease caused by xenobiotics in general as well as to idiopathic autoimmunity.

The immune response is subject to individual variability at all levels

All the components of the immune system involved in recognition and memory and in the nature, vigour and distribution of responses to antigenic challenge may be affected by the genotype and phenotype of the exposed person. They are likely to be greatly influenced by the individual genotype as well as by phenotype effects, and so are likely to vary greatly between individuals, depending on constitutional factors and on any previous exposure of the individual. Although immune responses do follow conventional types of dose-response relationship, the end effect is greatly modified by prior sensitisation. There is a considerable range of individual responses in conditions involving the immune system, as is well shown in the variability of the common immunological disorders of asthma and contact dermatitis, although strong sensitisers may be able to overcome much of the difference in the responsitivity of the individual.

Piroxicam induced Stevens-Johnson syndrome

Stevens-Johnson syndrome in a 63-year-old Japanese woman is described. Oral provocation test revealed the causative agent to be piroxicam.

Mechanisms of drug eruptions: Part I

The pathogenetic mechanisms underlying common, and less common but severe, adverse cutaneous drug reactions are reviewed. Pharmacogenetic variability may account for a susceptibility to serious drug reactions to sulphonamides and anticonvulsants, as well as to lupus erythematosus (LE)-like syndrome. Exanthematous drug reactions may have an immunological basis. Cell mediated cutaneous drug reactions, including lichenoid reactions, LE-like syndrome, fixed drug eruption, erythema multiforme, Stevens-Johnson syndrome and toxic epidermal necrolysis, will inevitably involve elements of the skin immune system. Graft-versus-host disease provides a useful model for aspects of these drug-induced disorders. Urticaria, angioedema, anaphylaxis and anaphylactoid reactions may involve Type I immunoglobulin (Ig)-mediated or Type III hypersensitivity, or may be caused by pharmacological, non-allergic means. Drug-induced vasculitis, serum sickness and the Arthus phenomenon are manifestations of the immune complex disease. Drug-induced pemphigus may involve immune dysregulation, but several thiol-containing drugs are able to cause antibody-independent acantholysis directly.

HLA-D region genes and rheumatoid arthritis (RA): importance of DR and DQ genes in conferring susceptibility to RA

The distribution of HLA-D region antigens was studied in three groups (I, IIa, and IIb) of patients with rheumatoid arthritis (RA): group I comprised 43 patients with mild, non-progressive RA, controlled by non-steroidal anti-inflammatory drugs without progression or erosions; group II comprised 94 patients with severe disease, who had earlier been treated with non-steroidal anti-inflammatory drugs and all had incomplete response requiring treatment with gold (sodium aurothiomalate). Of these, 46 patients (group IIa) responded to gold and the disease was well controlled, and the remaining 48 patients (group IIb) did not respond to gold and developed gold induced toxic reactions, including thrombocytopenia or proteinuria, or both. HLA-D region antigens were defined by serological and molecular (Southern blot analysis and oligonucleotide typing) techniques. The results show that DR4 was significantly increased in all three groups of patients. The prevalence of DR1, or DR1 in DR4 negative patients, and DR3 and DR4 associated DQw7 specificities, however, showed differences in these three groups of patients. The prevalence of DR1 and of DR1 in DR4 negative patients was increased only in patients with mild (group I) RA, but not in patients with severe (groups IIa and IIb) disease. On the other hand, the prevalence of DR4 associated DQw7 was significantly increased in patients with severe disease, but not in patients with mild RA. In addition, DR3 was significantly increased only in patients with severe disease who developed gold induced toxic reactions (group IIb). These data suggest that the HLA-D region genes which cause susceptibility to mild RA may be different from those causing susceptibility to severe RA. The results suggest that both DR and DQ (A, B) genes may be important in conferring susceptibility to RA: DR in mild disease and DQ in severe RA.

HLA system and penicillamine induced pemphigus in nine cases of rheumatoid arthritis

Nine cases of penicillamine induced pemphigus (PIP) in rheumatoid arthritis patients are reported. Clinical, histological and serological data were compared with previously published cases. No correlation between the occurrence of HLA A, B, DR antigens and PIP was found, even when the data was combined with that from 13 cases described in the literature. The clinical and histological polymorphism of PIP and its unpredictable outcome are emphasized.

Polymorphism of major histocompatibility complex extended haplotypes bearing HLA-DR3 in patients with rheumatoid arthritis with gold induced thrombocytopenia or proteinuria

The distribution of DR3 and of extended haplotypes bearing DR3 was studied in three groups of subjects: 35 patients with rheumatoid arthritis (RA) with gold induced thrombocytopenia or proteinuria, 185 patients with RA without these side effects, and 300 normal healthy controls. The extended haplotypes bearing DR3 were analysed with cDNA probes for DR alpha, DR beta, DQ alpha, and DQ beta genes. The data showed that the prevalence of DR3 was significantly higher in patients who developed gold induced thrombocytopenia or proteinuria than in normal controls or patients with RA without these side effects. Distribution of three extended haplotypes bearing DR3 (B8, DR3; B18,DR3; non-B8,non-B18,DR3) in patients with RA with thrombocytopenia or proteinuria was significantly different from that in normal controls, but not from that in patients with RA without these toxic reactions. Southern blot analysis of DR, DQ genes with cDNA probes showed that the extended haplotype bearing B8,DR3, which carries DQA2.1 and DQB2.1 genes, was present in a significantly higher proportion of patients with RA with gold induced thrombocytopenia or proteinuria (22/24, 92%) than in patients with RA without these side effects (32/45, 71%) or normal subjects (40/61, 66%). The data suggest that the genomic region on chromosome 6 involved in susceptibility to gold induced thrombocytopenia or proteinuria should be extended to the DQA2, DQB2 gene loci.

Rheumatoid arthritis

The results of family and twin studies suggest that RA may result from an interaction between an oligogenic susceptibility and unknown environmental factors. Part of this genetic predisposition is accounted for by genes within the MHC where there is a well-documented association with HLA-DR4. Studies of DR and other MHC variants have shown different associations with particular subgroups. One subgroup is Felty's syndrome where there is a strong association with DR4, as well as associations with DQ-beta and C4B null variants when DR4-matched Felty's and RA subjects are analysed. These DQ-beta and C4B null variants may characterize a single haplotype which is associated with extra-articular disease. A further rheumatoid subgroup characterized by circulating antibodies to native type II collagen, shows an association with HLA-DR3 and 7. Genes on chromosome 14 may also influence susceptibility to RA, probably by interaction with MHC genes and there are different Gm associations for DR4-positive and collagen-antibody-positive rheumatoid subgroups. HLA and Gm markers so far identified only account for a small part of the total genetic predisposition to RA and a third or further loci may also be involved. Possible candidates include T-cell alpha- and beta-chain genes and immunoglobulin light chain genes. One present concept of the genetic predisposition to RA is of several independent immunogenetic pathways each including interactions at two or more loci.

Some methodological problems in the assessment of complementary therapy

The increased interest of the public and the medical profession in complementary forms of therapy introduces an urgent need for proper assessment of efficacy. This growth in popularity suggests that complementary therapies are effective in some circumstances, but without objective assessment neither the public nor the medical profession can be sure. Rigorous scientific assessment is required, but the nature of complementary therapy is such that double-blind randomized controlled trials, as usually conducted, are rarely applicable, and alternative approaches are needed. At its best, complementary therapy is designed individually for each patient, and few treatments can readily be applied 'blind'. These are the main problems in trial design but complementary therapists are also aware of the importance of body-mind interactions: they see the 'placebo effect' as an integral part of treatment which needs investigation, and they question the validity of clinical trials in which the patient's will is not fully engaged through lack of information, and of those not asking the patients if they feel better. The problems are examined and alternative approaches suggested. The paper raises the question of whether they are only problems for complementary medicine.

Gold induced thrombocytopenia: 12 cases and a review of the literature

Gold induced thrombocytopenia is immune mediated, with the production of platelet associated IgG leading to peripheral platelet destruction. An association with HLA-DR3 has been demonstrated. Corticosteroid therapy is effective in treatment, although other modes of therapy may be as efficacious.

HLA haplotypes in non-familial rheumatoid arthritis

The frequencies of HLA-A, B, C, DR, and BF haplotypes in 44 unrelated Caucasian patients with definite seropositive rheumatoid arthritis (RA) were compared with haplotype frequencies in controls. Overall, the patients had an increased risk for HLA-DR4, DR3, and DR2 antigens, but frequencies of certain DR4 or DR3 haplotypes were not increased, suggesting the importance of other HLA loci for the evaluation of risk. The presence of DR4 alone was not found to produce an increased risk for RA since the frequencies of certain DR4 haplotypes were similar in patients and controls. Increased frequencies of HLA-B18, DR4, HLA-B15, DR4, and HLA-A1, B8, Cw7, DR3 haplotypes were found in patients. RA susceptibility has been found to be associated with the last two haplotypes in some studies of multiple case families, suggesting that similar genetic mechanisms may underlie the disease in familial and sporadic forms.

Adverse reactions with oral and parenteral gold preparations

Auranofin (triethylphosphine gold), an oral gold preparation, has recently been made available, and along with injectable gold preparations, is of therapeutic value for rheumatoid arthritis. Serious gold toxicity is uncommon, and drug-related deaths rare. Many potential adverse reactions are similar, including dermatitis, stomatitis, thrombocytopenia, leucopenia, and proteinuria, generally with increased incidence in the injectable gold-treated patients. Oral gold is associated with benign lower gastrointestinal side effects, including diarrhoea, loose stools and abdominal cramps that are often dose-related and resolve spontaneously. The incidence of severe reactions such as thrombocytopenia, aplastic anaemia and exfoliative dermatitis is lower with oral gold than injectable preparations, and contributes to a superior risk-benefit ratio. The treatment of gold toxicity depends on the type and extent of organ involvement.

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.

Predictive value of mean platelet volume in gold induced thrombocytopenia

In rheumatoid arthritis the mean platelet volume does not alter with the institution of parenteral gold therapy and with long term gold therapy. It appears to have no value in predicting the onset of thrombocytopenia. It may, however, predict a haemorrhagic diathesis once gold induced thrombocytopenia is established.

Association of HLA DR1 with high D-penicillamine binding to monocytes in females

Binding of D-Penicillamine (D-Pen) to human monocytes was examined by flow cytometry with fluorescent D-Pen conjugate. Cells from HLA DR1-positive healthy females bound significantly more D-Pen than cells from DR1-negative healthy females (P = 0.015), and DR1 was associated with the highest binding among HLA DR antigens. In contrast, DR4 was associated with the lowest binding in healthy females. A difference in D-Pen binding between healthy females who were DR1-positive, DR4-negative and those who were DR1-negative, DR4-positive was statistically significant (P = 0.026). Neither healthy females nor healthy males showed significant associations of D-Pen binding with HLA A, B, or C antigens, nor did healthy males show an association between strength of D-Pen binding and any DR antigens.

HLA-DR antigens in gold-induced neutropenia

We studied the clinical courses of 9 patients who developed acute gold-induced neutropenia with marrow aplasia. Eight of these carried HLA-DR4, compared with only 2 of 9 who had mild, chronic, isolated neutropenia (P less than 0.05). Only 1 of 9 patients with myelotoxicity carried HLA-DR3. We conclude that these groups are immunogenetically distinct, and that HLA-DR3 is not a significant risk factor for severe gold-induced neutropenia.

Penicillamine-induced proteinuria: risk factors

Twenty-six of 300 patients (9%) with rheumatoid arthritis (RA) developed penicillamine-induced proteinuria. The mean daily dose and duration of therapy at onset of proteinuria were 591 mg and 9 months, respectively, while the mean duration of proteinuria was 5.5 months. However, six patients developed proteinuria at 250 mg/d and six after 9 months of therapy. Twelve patients were successfully either restarted (five) or maintained (seven) on penicillamine with resolution of proteinuria. No permanent renal impairment occurred. Positive risk factors included the presence of HLA-B8 and DR3 and prior gold-induced proteinuria. Patients with prior gold-induced proteinuria should be observed more carefully, but tissue typing is not recommended as proteinuria is reversible. Furthermore, penicillamine can be restarted or maintained in these patients if the RA has responded favorably to the drug.

Association of different HLA antigens with various toxic effects of gold salts in rheumatoid arthritis

An association of gold induced proteinuria with HLA-D(R)3 has been reported. To investigate other possible relationships between gold toxicity and HLA antigens we studied 85 patients with rheumatoid arthritis (RA) divided into four subgroups: patients with gold induced interstitial pneumonitis, mucocutaneous lesions, proteinuria, and patients without gold toxicity. The HLA frequencies in patient groups and 283 healthy controls were compared in different pairwise combinations. Gold induced pneumonitis was associated with HLA-B40 and Dw1. An association between gold induced proteinuria and HLA-Dw3 was also seen. The increased prevalence of Dw4 in RA was observed only in the control patient group without gold induced side effects. The frequencies of HLA-B7 and Dw2 were decreased in all patient groups compared with the control population. These results further support the view of the heterogeneity of RA as manifested by the unique HLA associations with resistance and susceptibility to gold induced side effects characterising different subgroups.

HLA-D antigens in rheumatoid arthritis and toxicity to gold and penicillamine

The frequencies of HLA-D antigens were investigated in 77 Finnish patients who met the ARA criteria of classical or definite rheumatoid arthritis. The control material consisted of healthy blood donors. HLA-Dw4 was significantly (p less than 0.01) increased and HLA-Dw2 significantly (p less than 0.01) decreased in the patients. All HLA-Dw4-positive patients belonged to the seropositive group and in comparison with controls HLA-Dw4 antigen was increased highly significantly (p less than 0.001) in the seropositive patients. With respect to HLA-Dw4 antigen, the seropositive and the seronegative group differed significantly (p less than 0.05). All patients had received penicillamine treatment and 75 of them gold treatment before penicillamine. No significant associations were noted between any HLA-D antigen and gold or penicillamine toxicity. The previous gold toxicity seemed to be a significant factor with respect to the subsequent penicillamine toxicity.

HLA antigens and toxic reactions to sodium aurothiopropanol sulphonate and D-penicillamine in patients with rheumatoid arthritis

One hundred and forty-one patients with rheumatoid arthritis treated with aurothiopropanol sulphonate or D-penicillamine, or both were examined for HLA antigens to investigate the genetic influence on the occurrence of different adverse reactions during therapy. All 13 patients possessing HLA-DR3 had toxic reactions. The relative risk for DR3 positives of developing skin eruptions or proteinuria was calculated to be 10.5 times and seven times respectively that of DR3 negatives. The incidence of DR7 antigen in 94 patients with toxic reactions was significantly decreased (11% compared with 28% in controls) suggesting a protective role for this antigen.

HLA antigens and adverse drug reactions to sodium aurothiomalate and D-penicillamine in patients with rheumatoid arthritis

The association between HLA antigens and adverse drug reactions (ADR), (e.g. proteinuria, haematological abnormalities, stomatitis, diarrhoea and dermatitis) in rheumatoid arthritis (RA) to sodium aurothiomalate (gold) and to D-penicillamine (PA) were studied in 32 patients. Thirty-eight RA patients treated with gold and PA, and with no ADR to these drugs, were used as controls. The frequency of HLA B8 was significantly (p less than 0.05) increased among RA patients with ADR compared to plasma donors. DR3 was also significantly increased (p less than 0.05) in RA patients with haematological ADR compared to plasma donors. Haematological ADR occurred significantly (p less than 0.05) more often in DR3 positive patients (55%) than among DR3 negative RA patients (27%).

HLA antigens and seronegative rheumatoid arthritis

HLA antigens and clinical features in a series of 46 Caucasian patients (40 females, 6 males) and definite repeatedly seronegative rheumatoid arthritis (RA) of more than two years' duration (mean 11.6 years) were compared with those in 77 seropositive RA patients and 110 controls of the same ethnic and geographic origin. Seronegative RA appeared to be less often erosive than seropositive RA, and seronegative patients had fewer extra-articular features. The frequency of the HLA antigen DR1 was raised in seronegative patients as compared with controls (p = 0.006, relative risk = 3) and with seropositive patients (p less than 0.05). HLA-DR4 was slightly increased in seronegative patients compared with controls (p less than 0.05) but was clearly less so than in seropositive patients (p less than 0.005). Early onset of disease was very significantly associated with HLA-DR1 in seronegative patients (p = 0.007), whereas HLA-DR4 was present more frequently in seropositive patients with onset prior to age 35 (p less than 0.05). No correlation between HLA antigens and intolerance to drugs was found in seronegative patients, whereas in seropositive patients side effects to gold salts were associated with DR3. These results suggest that seropositive and seronegative RA have distinct HLA-DR associations, especially in disease of early onset, in addition to well established clinical differences.

Mammary gigantism and D-penicillamine

Mammary gigantism is a rare complication of D-penicillamine treatment. We report a further case with pathological and endocrine details together with a review of the seven cases previously reported and possible mechanisms.

Inherited predisposition to iridocyclitis with juvenile rheumatoid arthritis: selectivity among HLA-DR5 haplotypes

HLA-DR5 is associated with a chronic iridocyclitis and juvenile rheumatoid arthritis with onset in early childhood. Previously published data provided indirect evidence for selective linkage between two HLA-B alleles and HLA-DR5. To test this observation further, 38 families, the probands of which have chronic iridocyclitis and juvenile rheumatoid arthritis, were HLA typed so that haplotypes associated with disease could be established. HLA-DR5 was linked to HLA-Bw44 or to HLA-Bw35 and to HLA-Cw4 in the majority of haplotypes obtained in the probands. Both HLA-Bw44, -DR5 and HLA-Bw35, -Cw4, -DR5 occurred more commonly in the proband haplotypes than in the control haplotypes. The frequency of the haplotype HLA-Bw44, -DR5 was 0.133 compared with 0.007 (X2 = 27.04, P less than 10(-6] and for HLA-Bw35, -Cw4, -DR5, it was 0.093 compared with 0.11 (X2 = 13.83, P = 0.0002). The relative risks were 20.77 and 9.23, respectively, versus 3.52 for HLA-DR5 alone. HLA-Bw44 occurred much more commonly in proband HLA-DR5 haplotypes (0.455) compared with control HLA-DR5 haplotypes (0.067) (X2 = 8.26, P less than 0.01). Not all HLA-DR5-bearing haplotypes predisposed equally to chronic iridocyclitis and early-onset pauciarticular juvenile rheumatoid arthritis.

HLA-DR genotype risks in seropositive rheumatoid arthritis

We studied the distribution of HLA-A, B, C, and -DR antigens in 77 Caucasian patients with sero-positive rheumatoid arthritis. Forty-four patients were genotyped and compared with the control panel of 110 unrelated Caucasian genotyped donors. The data obtained confirm the association of DR4 with RA, and reveal an increased risk of disease for patients carrying DR1, DR2, and DR3, compared to the risk for those carrying other antigens, such as DR5, DRw6, and DR7. There is a higher risk for DR4/4 homozygotes than for DR4/1, DR4/2, or DR4/3 heterozygotes. DR4/5, DR4/6, and DR4/7 have a lower risk than the previously mentioned genotypes. The genotype risks are compatible with the inheritance of a single, linked genetic determinant of disease susceptibility, but we are unable to distinguish between recessive and dominant inheritance of susceptibility using the "antigen-frequencies-amongst-diseases" method. DR4 seems to be more frequent in patients in whom onset occurs before the age of 35 (79% vs. 54% DR4 positive). A significant excess of DR3 + is observed in patients with toxic complications following treatment with gold salts (X2(1) = 8.96).

The relationship between aurothioglucose- and D-penicillamine-induced proteinuria

We studied patients with rheumatoid arthritis who have been treated with aurothioglucose (Au) and subsequently with D-penicillamine (DP), and who developed drug-induced proteinuria, over a 10-year period. Twelve patients developed Au-induced and 19 DP-induced proteinuria. Of the 12 patients with Au-induced proteinuria, only 2 (17%) developed DP-induced proteinuria, indicating a slightly increased risk as compared with the overall incidence (9.3%) of this reaction in 168 DP-treated patients. In addition, only a minority (2 out of 19, 10.6%) of patients with DP-induced proteinuria had previous Au-induced proteinuria. These data may indicate that different mechanisms are operative in Au and DP-induced proteinuria, as is also suggested by the finding that HLA-DR3 was present more frequently in the latter (50%) than in the former (21%). A history of previous Au-induced proteinuria is insufficient reason to deny these patients the benefits of subsequent treatment with DP.

Association of HLA antigens, toxic reactions and therapeutic response to auranofin and aurothioglucose in patients with rheumatoid arthritis

To investigate the possible relation between HLA antigens and either favourable clinical response or toxic reaction to two different gold compounds, aurothioglucose and auranofin, a new orally absorbable gold compound, we studied 50 patients with rheumatoid arthritis prospectively. Of the 25 aurothioglucose-treated patients, response to treatment could not be evaluated in four patients because of early toxicity. Nine patients showed an excellent response, while 12 were moderate or non-responders. Four of the 9 excellent responders were HLA-DR3 positive, but none of the 12 moderate or non-responders possessed this antigen (P less than 0.025). In accordance with previous reports HLA-DR3 was found more frequently in patients developing toxicity on aurothioglucose than in those who did not (RR = 5.6). No association was found between HLA antigens and favourable clinical response in 25 auranofin-treated patients. Two of them showed a severe adverse reaction, neither of them being DR3-positive. HLA-DR3 positivity is associated not only with drug toxicity, but also with excellent respondership to aurothioglucose treatment.