Management of proteinuria secondary to penicillamine therapy in rheumatoid arthritis

To determine if a policy of continuing penicillamine therapy in successfully treated patients with rheumatoid arthritis in the presence of persistent proteinuria, was associated or not with resolution of this adverse effect, a computer record of patients receiving penicillamine for rheumatoid arthritis was searched for patients with persistent proteinuria and the case notes of these patients reviewed. Eleven patients with persistent proteinuria were identified, eight of whom did not have nephrotic syndrome and were continued on penicillamine with close monitoring. In 5 patients proteinuria resolved after 16-21 months; 3 developed peripheral oedema (2) or worsening of pre-existing hypertension and proteinuria (1). In one of these the proteinuria subsequently resolved and one died of unknown cause. Of the 3 initially nephrotic patients, two had resolved at the time of the study. Persistent proteinuria in penicillamine-treated patients with rheumatoid arthritis resolves with continued therapy in the absence of nephrotic syndrome but vigilance is required for the development of any complications.

Difficulties in the use of D-penicillamine in the treatment of rheumatoid arthritis

The difficulties encountered in administering D-penicillamine to 40 patients with rheumatoid arthritis (RA) over a six to 24 month period are recorded. Side-effects were frequent. Proteinuria occurred in 13 patients (33%) mainly in the fourth to the sixth month. Renal biopsies were performed in six patients and all showed light microscopy abnormalities. Electron microscopy performed in five patients revealed subepithelial deposits in all and in addition some had mesangial and subendothelial deposits. Seven patients (17.5%) developed eight episodes of thrombocytopaenia which was quickly reversed on cessation of treatment or reduction in dosage. On the positive side, there was significant improvement in most parameters of disease activity at six, 12 and 18 months compared to the pretreatment levels, but the results at two years were less impressive. Reduction in steroid dosage was considerable and was greater than half the mean pretreatment dose after two years but the absence of a control group makes the full significance of these uncertain. Patients on high and low dosage regimens were compared over a 12 month period of treatment. Although the differences were not statistically significant, withdrawals and side-effects were less frequent in the low dose group.