Gold sodium thiomalate Side Effects
Some side effects of gold sodium thiomalate may not be reported. Always consult your doctor or healthcare specialist for medical advice. You may also report side effects to the FDA.
For the Consumer
Applies to gold sodium thiomalate: intramuscular suspension
Get emergency medical help if you have any of these signs of an allergic reaction while taking gold sodium thiomalate: hives, sweating, vomiting; difficult breathing; swelling of your face, lips, tongue, or throat.
Call your doctor at once if you have a serious side effect such as:
unusual bleeding (nose, mouth, vagina, or rectum), purple or red pinpoint spots under your skin;
skin rash, bruising, severe tingling, numbness, muscle weakness, burning pain in your hands or feet;
pale skin, feeling light-headed, rapid heart rate, trouble concentrating;
itching or peeling of skin, hair loss, or problems with your fingernails or toenails;
white patches or sores inside your mouth or on your lips;
mouth pain, swollen tongue;
severe or ongoing diarrhea;
slow heart rate;
eye pain or vision problems;
flushing (warmth, redness, or tingly feeling);
feeling like you might pass out;
puffy eyes, swelling in your ankles or feet, weight gain, urine that looks foamy;
blood in your urine or stools;
chest pain, dry cough, wheezing, feeling short of breath;
nausea, upper stomach pain, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes); or
confusion, hallucinations, or seizure.
Other common side effects may include:
mild headache or dizziness;
mild diarrhea, stomach cramps;
joint pain; or
a metallic taste in your mouth.
This is not a complete list of side effects and others may occur. Call your doctor for medical advice about side effects.
For Healthcare Professionals
Applies to gold sodium thiomalate: intramuscular suspension
Adverse effects may occur at any time during parenteral gold therapy. Blood or plasma concentrations do not appear to correlate with the development of toxicity but the cumulative dose may. Severe side effects are more likely to occur with total doses greater than 400 to 800 mg. Serious side effects result in discontinuation of gold sodium thiomalate in up to one-third of patients by one year of therapy.
Pruritus and rash may be early warning signs of gold toxicity. Any eruption during gold sodium thiomalate therapy should be considered a gold reaction until proven otherwise. Gold sodium thiomalate may be successfully reintroduced following complete resolution of symptoms in some patients who develop mild dermatologic reactions. Therapy should be cautiously reinstituted using small doses with a gradual titration.
Skin pigmentation, known as chrysiasis, characterized by a gray or blue discoloration of sun-exposed skin has been reported following the use of parenteral gold salts.
There are data to suggest that the development of gold-induced skin rash is associated with remission in rheumatoid arthritis patients. In one retrospective study of 247 patients treated with parenteral gold, 31 patients experienced dermatologic toxicity. All 31 patients entered remission as defined by clinical and laboratory parameters. None of the patients who developed other types of toxicity went into remission. Further study is needed to validate these findings.
Dermatologic reactions are among the most common side effects of gold sodium thiomalate therapy. Allergic contact dermatitis, pruritus, nonspecific rash, and maculopapular rash have been reported as have more serious reactions, including papular or vesicular eruptions, exfoliative dermatitis, and toxic epidermal necrolysis. In addition, erythema anulare centrifugum, granuloma anulare, pityriasis rosea, lichen planus, discoid eczema, and skin pigmentation or chrysiasis have been associated with parenteral gold therapy. Partial or complete hair loss has also been associated with the use of this drug.
Mucous membrane reactions occur commonly and may prompt discontinuation of therapy. Stomatitis, glossitis, gingivitis, and oral ulcers can occur and may be preceded by a metallic taste sensation. Conjunctivitis has also been reported.
Patients should be instructed to practice good oral hygiene in an attempt to reduce the incidence and severity of oral mucocutaneous reactions.
In the event that mucocutaneous reactions worsen or spread, systemic glucocorticoids may be necessary in addition to discontinuation of gold sodium thiomalate therapy.
One recent study found an increased frequency of HLA-DR1 antigens in rheumatoid arthritis patients who developed gold-induced mucocutaneous reactions compared to patients who did not develop such reactions. The authors of this study suggest that knowledge of the presence of HLA-DR1 may aid in the evaluation of risk versus benefit in given patients.
Hypersensitivity reactions include anaphylactic shock, syncope, thickening of the tongue, difficulty in swallowing and breathing, fever, and angioneurotic edema. Patients should be observed in the recumbent position for evidence of an immediate hypersensitivity response for at least 15 to 30 minutes after each injection.
Decreases in hemoglobin as well as leukopenia, granulocytopenia, and thrombocytopenia may be warning signs of gold toxicity. Any rapid decline in platelet counts or a platelet count of less than 100,000/mm3 necessitates discontinuation of gold sodium thiomalate. Gold therapy should not be reinstituted unless the thrombocytopenia is shown to be unrelated to gold.
Gold-induced thrombocytopenia appears to involve peripheral destruction of platelets. Bone marrow aspirates in cases of gold sodium thiomalate or other gold salt-induced thrombocytopenias revealed normal or increased numbers of megakaryocytes. While elevated platelet-associated IgG was present in some cases, in others, evidence of circulating antibodies could not be found.
In addition to discontinuation of gold therapy and initiation of glucocorticoid therapy, treatment of various refractory gold-induced blood dyscrasias has included the use of antithymocyte globulin, chelating agents, granulocyte colony stimulating factor, granulocyte-macrophage colony stimulating factor, and high-dose intravenous gamma globulin as well as bone marrow transplantation.
Hematologic abnormalities associated with parenteral gold salts include thrombocytopenia (3% to 5%), eosinophilia (5%), leukopenia (up to 1.4%), anemia, agranulocytosis, pancytopenia, and aplastic anemia. In addition, lymphadenopathy has been reported.
Gold deposits in the lens and cornea appear to be dose related. Such deposits are not usually associated with visual disturbances and typically disappear within months of discontinuing therapy.
Ocular side effects, most commonly conjunctivitis, may require cessation of therapy. Gold deposits in the cornea and, occasionally, in the lens, as well as iritis and corneal ulcers have been reported. A case of transient monocular visual loss in association with a nitritoid reaction has also been reported.
Clinically significant proteinuria or hematuria or increasing proteinuria may require cessation of gold therapy. Renal toxicity is usually reversible if recognized early and gold sodium thiomalate is discontinued. Further therapy with gold salts is contraindicated in this setting.
There are data which suggest that the risk of proteinuria may be increased in patients with HLA-DR3 antigens. In addition, onset of proteinuria may be faster in this population.
Renal side effects of gold salts include proteinuria (3% to 19%), hematuria, nephrotic syndrome, glomerulonephritis, and interstitial nephritis. In addition, extremely rare cases of acute tubular necrosis have been reported.
Cholestasis is the most common form of gold-induced hepatotoxicity and typically presents early in the course of gold therapy. While usually reversible upon discontinuation of the drug, fatal cases of intrahepatic cholestasis have been reported. The presence of rash and eosinophilia in many cases suggests that this form of hepatotoxicity is due to a hypersensitivity reaction.
Several cases of massive hepatic necrosis have also been reported in the literature. In three fatal cases, cumulative doses of parenteral gold were 75 mg, 385 mg, and greater than 2500 mg, respectively.
Hepatotoxicity is a rare but potentially serious complication of gold sodium thiomalate therapy. Jaundice, cholestatic hepatitis, hepatic necrosis, and granulomatous hepatitis have been associated with gold therapy.
Vasomotor, or nitritoid, symptoms typically include faintness, palpitations, flushing, weakness, sweating, nausea, and vomiting. This reaction may be more severe in the elderly and may result in myocardial infarction or central nervous system injury.
Several case reports suggest that concomitant therapy with angiotensin converting enzyme inhibitors may increase the risk of nitritoid reactions in some patients.
Cardiovascular side effects are rare and typically limited to a vasomotor or nitritoid reaction. Serious cardiovascular events, such as bradycardia or myocardial infarction, have been reported in association with nitritoid reactions due to gold sodium thiomalate.
Gastrointestinal side effects are uncommon but may include nausea, vomiting, abdominal cramps, diarrhea, gastritis, ulcerative proctitis, enterocolitis, colitis, and pancreatitis. Gold-induced colitis has been fatal in some cases. In addition, at least one case of sialadenitis has been reported secondary to obstruction caused by deposits of gold salt compounds in the parotid glands.
Patients with gold-induced lung disease may present with shortness of breath, nonproductive cough, and/or dyspnea on exertion. If drug-induced lung disease is suspected, gold therapy should be discontinued. If infection has been excluded, glucocorticoid therapy may also be indicated.
As rheumatoid arthritis may be associated with pulmonary changes, assessment of causality in cases of suspected gold-induced pulmonary toxicity is difficult. However, gold-induced lung disease tends to be associated with an acute onset of symptoms, often shortly after gold therapy is initiated (typically after a cumulative dose of approximately 500 mg). In addition, positive dechallenges and rechallenges tend to support gold as a causative factor.
Respiratory side effects, while uncommon, may be serious and include gold bronchitis, bronchiolitis obliterans, interstitial pneumonitis, alveolitis, and fibrosis. In addition, pharyngitis and tracheitis have been reported.
Nervous system side effects are rare. Peripheral neuritis, encephalopathy, encephalomyelitis, and Guillain Barre-type syndrome have been reported. Myokymia (persistent quivering of the muscles) may be a clinical sign of gold-induced neurotoxicity.
Gold-induced immunoglobulin deficiencies have been observed in patients treated for rheumatoid arthritis.
Decreased production of immunoglobulins A, M and G have occurred during gold treatment.
Nonvasomotor postinjection reactions, including arthralgias, myalgias, transient stiffness, and constitutional symptoms, are usually mild and self limited but may be severe enough to require discontinuation of therapy. Cautiously switching to aurothioglucose may obviate these reactions.
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