Parenteral gold (Myocrisin)

Avoid in CKD 5 (eGFR <15)

• Initiation: test dose 10mg by deep IM injection

then

• 50 mg weekly until there is a response when improvement in symptoms/signs has stopped or 20 doses have been given

• Benefit not expected until at least 10 doses given
• When response, increase injection interval to 2 weeks and then once monthly
• Maintenance: usual dose is 50 mg monthly

• Pre-treatment FBC, U+E, CRP, LFTs Inc albumin urinary dipstick for blood and protein

then

• FBC, U+E, CRP, LFTs inc albumin fortnightly for 6 weeks after dose stable then monthly for 3 months then 3 monthly but urinalysis for blood and protein prior to each injection. 
• The FBC result need not be available prior to the injection

Entering the results into a monitoring booklet will ensure that trends are not missed. Patients who do not attend for monitoring should be warned of the risk that serious adverse effects may go unnoticed. In the event of persistent failure to attend for monitoring please inform the Rheumatology department.

The patient should be asked about rash or oral ulceration before each injection.

• WBC <3.5 – withhold and discuss with rheumatology
• Neutrophils <1.6
• Platelets  <140
• Eosinophilia >0.5 – caution and increased vigilance required
• 2 + proteinuria on more than one occasion) – check MSU and treat. If sterile and persists, withhold and discuss
• ALT or AST >100
• Unexplained albumin <30g/l
• >30% rise in creatinine over 12 months
• MCV >105 with normal TSH and haematinics
• Rash or oral ulceration - withhold and discuss
• Abnormal bruising or sore throat -withhold until FBC available

• Treatment is continued indefinitely providing it remains effective and there are no significant side effects
• Parenteral gold takes about 3 months to become effective, but may take up to 6 months
• During this period there are likely to be continued symptoms or signs of disease activity
• It is reasonable to use IM Depo steroid (Kenalog 40mg or Depo Medrone 80mg) up to monthly, depending on the requirements of the individual patient
• The dose required is small (eg monthly Kenalog 40mg = 1.6mg prednisolone daily)
• If IM steroids are still required 3 months after starting treatment, the parenteral gold should be increased to fortnightly until control is regained, then reduced back to monthly
• If 20 doses have been given without effect, the parenteral gold should be stopped

• Disease modifying drugs will not prevent all flares.
• These can be managed with IM Depo steroid as outlined above.
• If flares become more frequent, or the disease fails to settle between flares, the dosage should be increased, or an alternative discussed with the rheumatologist.

Common effects are in bold type.

Mucocutaneous

• mild rashes and pruritis
• severe erythematous rashes
• exfoliative dermatitis
• photosensitivity

Haematological

• neutropenia
• thrombocytopenia
• eosinophilia
• rarely, aplastic anaemia

Gastrointestinal

• nausea
• reversible taste disturbance and metallic taste
• mouth ulcers
• diarrhoea

Other

• proteinuria
• nephrotic syndrome
• haematuria
• cholestatic hepatitis
• colitis
• pulmonary fibrosis

Secretaries 01387 241776

• Iseabail Graham
• Caron Cowen

Helpline 01387 241095 (answering machine)

Nurse Specialists:

• Petra Cannon
• Ingrid Crane
• Andrew Wilson 

Department of Rheumatology doctors via Switchboard 01387 246246

• Dr A Russell - Consultant
• Dr R Akintayo - Locum Consultant
• Dr A Drever - Associate Specialist
• Dr L Moran - Associate Specialist