Læknablaðið : fylgirit - 01.05.1978, Page 38

O Strandberg
Department of Rheumatology
Danderyd Hospital
Stockholm
Sweden
Patients with rheumatic diseases have been
treated with penicillamine since October, 1974.
A low dosage scheme according to Day et al
(1974) has been used. Totally 191 patients have
been treated, mainly patients with rheumatoid
arthritis, seropositive, but also a small number
of other diagnoses are represented (Table I).
About 90 per cent of the material to be presented
concerns out-patients.
Dosage: 150 mg penicillamine/day one month,
increasing the dose monthly with 150 mg/day up
to 450 mg/day, more seldom the long-term dosage
exceeds 750 mg/day. Concomitant therapy consists
of copper sulphate 5 mg/day (not including in
patients starting therapy after March, 1976), further
symptomatic anti-inflammatory drugs, salicylates,
indomethacin, napraxen, steroids locally. No
phenylbutazone has been given.
Controls of laboratory values are made every
second month, patients taking 600 mg or more a
day controlled monthly. The patients are seen
with 3 or 4 months interval.
The A.R.A. diagnostic criteria (1) are used.
Laboratory methods: Agarose gel electrophoreses
(4), serum albumin and haptoglobin are determined
with chemical methods (3,6) alpha-l-antitrypsine,
orosomucoid, C ’ 3 and C '4 complement fractions,
and immune globulins are determined with electro
immune assay (5).
This report concerns 120 patients, treated 6
months or for a longer time, however, the adverse
reactions to be reported concern all the 191
patients. Table n shows that the means for the
ESR is reduced significantly the mean haemoglobin
concentration has increased significantly, and
the mean platelet count has decreased signifi-
cantly. This decrease of platelet count I do
not believe to be a matter of bone marrow
depression, patients with active rheumatoid
disease often have elevated platelet count and
rheumatic nodules as laboratory and clinical
signs of vasculitis. During therapy with
penicillamine there is a normalization of the
platelet count, reduction of the rheumatic nodules,
possibly a reduction in vasculitis.
Table III shows that a significant decrease of
PENICILLAMINE TREATMENT
OF RHEUMATIC DISEASES IN
AN OUT-PATIENT UNIT
the acute phase electrophoresis parameters alpha-
1-antitrypsine, orosomucoid and haptoglobin is
obtained during therapy.
Table IV shows a significant decrease in the
C "3 complement fraction, but no change in the
C 4 fraction, in some cases consumption of C 4
seems to dissappear during therapy. A signifi-
cant reduction of the immune globulins has been
obtained during therapy.
There has been no changes in the titres óf
rheumatoid factor (agglutination of sensitized
human erythrocytes).
I have not had the time and opportunity to
perform observer assessment with score and
articular index. Reduction in synovitis and
rheumatic nodules and articular and muscular
pain begin 2-3-4 months after starting the
penicillamine therapy, low activity patients
respond earlier.
The adverse reactions and causes for with-
drawal from therapy is recorded in Table V.
The proteinuria is of glomerular type according
to urine and plasma electrophoresis. The
proteinuria is reversible, 1-6 months have
elapsed from the start to normalization.
Seven patients could not take penicillamine
because of rash, 2. of them had an earlier known
penicillin allergy, this reaction came immediately
after starting the medication. Two patients had
pluriorificial irritation of the Stevens-Johnson
type. One patient ceased taking penicillamine
because of diplopia, after 3 weeks medication.
Itching on a dose level of 750-900 mg/day in
a few cases was controlled by dose reduction and
giving periactin.
One patient died suddenly of a cerebral vascular
catastrophe. I cannot see any reason to suspect
peniciUamine in that connection, the patient had
hypertension.
The total withdrawal frequency because of
adverse drug reactions in this material is at the
present moment 10 per cent.
Two out of four cases with psoriatic arthropathy
ceased taking penicUlamine after short time
because of exacerbation of the dermatological
symptoms.
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