What to Know About Gold Therapy for Rheumatoid Arthritis

Gold therapy is a disease-modifying treatment for moderate to severe rheumatoid arthritis (RA) and other inflammatory diseases. It involves the administration of gold salts—a component of the metal that appears to have anti-inflammatory properties—either orally or via intramuscular injection in an effort to quell symptoms and potentially put the disease into remission.

Initially developed in the 1920s, gold therapy—a.k.a. aurotherapy or chrysotherapy—was the main treatment for RA until the introduction of methotrexate in the 1990s. The move away from gold therapy was due not only to the superior effectiveness of newer RA treatments, but the therapy's harsher side effects (e.g., liver toxicity, kidney damage, and bone marrow diseases).

Gold therapy, while not commonly used in the treatment of RA today, is still available in oral capsule form as Ridaura (auranofin). The injectable forms—Myochrysine (aurothiomalate) and Solganal (aurothioglucose)—are no longer manufactured.

Uses

Gold therapy is used in both adults and children to treat rheumatoid arthritis and other inflammatory conditions such as psoriatic arthritis and juvenile rheumatoid arthritis. The treatment appears to be most effective when given in the early stages of arthritis, although it may offer benefits to anyone with active joint pain and swelling.

While the exact mechanism of gold's anti-inflammatory effect is not fully understood, gold salts appear to stop cells from releasing chemicals that can harm tissues.

Research suggests that gold is stored in lysosomes where it inhibits the processing of antigenic agents (any substance that stimulates the production of antibodies) and the release of proinflammatory cytokines (proteins that serve as messengers between cells). It is therefore classified as a disease-modifying anti-rheumatic drug (DMARD).

In the mid-20th century, researchers found injectable gold has clinically significant benefits in the short-term treatment of RA. But the evidence for oral gold therapy is not as promising as injected gold salts.

Oral gold was shown to be moderately effective when compared to a placebo and equally effective as Plaquenil (hydroxychloroquine) and methotrexate, but with greater potential for toxicity.

Side Effects

Some side effects of gold therapy are serious and a large part of why treatments like other DMARDs and biologic drugs are favored for RA. In fact, side effects lead to about one-third of patients discontinuing treatment before achieving its full effects.

That said, the most common side effects are mild. Some people do not experience any side effects at all. 

Side effects may arise at any time during the course of treatment. Be sure to tell your healthcare provider about any new symptoms you experience while taking gold therapy.

Common 

The most common side effects associated with gold therapy include: 

• Rashes 
• Mouth sores
• Metallic taste
• Thinning of hair
• Weakness, dizziness, or fainting immediately after treatment
• Upset stomach and diarrhea (oral therapy only)

These are all generally mild and may go away during the course of treatment.

Long-term gold therapy may result in a bluish discoloration of the skin to occur that can be permanent.

Severe

During the course of oral therapy and prior to each injection, your healthcare provider will test blood and urine for markers that indicate whether or not it is safe for you to continue gold therapy.

Serious side effects include: 

• Kidney damage: One in 10 patients may experience mild proteinuria. Prior to each treatment, a urine test will be done to check for protein. If positive, you will need to do a 24-hour urine collection. Proteinuria that exceeds 500 milligrams (mg) in 24 hours is an indication that gold therapy should be stopped. 
• Bone marrow damage: Though uncommon, some patients may develop aplastic anemia, granulocytopenia, or immune thrombocytopenia. These conditions are indications for ceasing gold therapy. Your healthcare provider will routinely test your blood to check for indicators of these concerns.
• Increased pain: Though rare, some people experience an increase in musculoskeletal pain that requires discontinuation of treatment.
• Liver damage: Though very rare, liver damage is an indication to stop treatment. Your healthcare provider will monitor your liver enzymes with routine blood work to watch for liver damage. 
• Open oral sores: If open sores occur in the mouth or throat, gold therapy should be stopped until the eruption heals, then restarted at a lower dose of 10 mg to 15 mg weekly (for injections), titrating up to the full dose.

Before Taking

Most rheumatologists no longer offer gold therapy to patients with arthritis. However, you may be able to find an alternative medicine provider who specializes in pain management or autoimmune disease that provides gold therapy.

Prior to starting gold therapy, your healthcare provider will consider the severity of your disease, the number of joints affected, your response to other treatments, and the length of time you have experienced symptoms.

Before starting and throughout your treatment, your healthcare provider will test your blood and urine samples to determine if gold therapy is safe for you.

Precautions and Contraindications

Before taking gold treatment, tell your healthcare provider if you are pregnant, planning to become pregnant, or are breastfeeding. The effects of gold therapy on unborn children and nursing newborns are unknown. Animal studies suggest a link between gold therapy and birth or developmental defects, so it's very likely an alternative treatment will be recommended to be safe.

Tell your healthcare provider if you have ever had a serious adverse reaction to gold therapy in the past. The treatment should not be initiated in anyone who has had previous serious side effects from gold.

If you have ever had a reaction to gold jewelry, alert your healthcare provider. This may not end up being an issue, however. A true gold allergy is rare, and those who have reactions to gold pieces are typically allergic to the nickel that is often mixed into the metal—not the gold itself.

Dosage

Gold therapy is currently only available as oral therapy. Production of intramuscular gold ceased in 2019 due to a global shortage of gold sodium thiomalate.

Oral Gold Therapy

Ridaura, oral gold therapy, is delivered as a capsule taken on a regular schedule as prescribed by your healthcare provider. Typically dosing is:

• Adults: 6 mg once a day or 3 mg twice a day. After six months, the dose may increase to 3 mg three times a day.
• Children: The correct dose will be determined by the prescribing healthcare provider.

Dosing is highly individualized. Be sure to follow your healthcare provider's instructions as written on the prescription label. If you have any questions, talk to your practitioner or pharmacist.

Ridaura can be taken with or without food, although taking it after a meal or light snack may help reduce stomach upset. Do not drink alcohol while taking this medication.

If you miss a dose, take it as soon as you remember, then take any remaining doses for that day at evenly spaced intervals. Do not take a double dose to make up for a missed one.

It commonly takes three to four months to see results from gold therapy, although it may to up to six months to achieve the full benefits of this treatment.

Intramuscular Gold Injections

When available, gold shots were administered as an intramuscular injection of Myochrysine or Solganal to the buttocks or arm in the healthcare provider's office weekly for the first 20 weeks. After that, the treatment frequency was tapered to every three or four weeks. Blood and urine tests were required prior to each gold injection.

The dosing started low and gradually increased over the first few weeks of treatment to build up your tolerance as follows:

• Adults and teenagers: Initial dose of 10 mg for the first injection, increase to 25 mg at the second visit, and then an increase to 50 mg a week until a response is achieved. The maximum total of gold administered during the course of treatment was not to exceed 1 gram.
• Children: Initial dose of 10 mg for the first injection, then an increase to 1 mg per kilogram of body weight for a maximum of 50 mg a week. After several months, the frequency of injections may have been decreased.

It could take four to six months before the full effect of gold shots became evident, which could last for several years.

Warnings and Interactions

Gold therapy should not be taken alongside other DMARDs, biologics, or antimalarial drugs as harmful interactions may occur. These include, but are not limited to:

• Arava (leflunomide)
• Azulfidine (sulfasalazine)
• Chloroquine
• Cimzia (certolizumab pegol)
• Enbrel (etanercept)
• Humira (adalimumab)
• Kineret (anakinra)
• Orencia (abatacept)
• Plaquenil (hydroxychloroquine)
• Remicade (infliximab)
• Rituxan (rituximab)
• Simponi (golimumab)
• Trexall (methotrexate)

Your healthcare provider may prescribe other types of RA medications, such as corticosteroids, analgesics, and non-steroidal anti-inflammatory drugs (NSAIDs), to ease symptoms while waiting for gold therapy to start working.