[Immunomodulating drugs in rheumatic diseases in adults and children].
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Biomedical subjects
Publications and source records attributed to E Munthe.
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It is postulated that the efficacy of sodium aurothiomalate and d-penicillamine could be partly dependent on the activity of sulphydryl groups. Free thiomalate, the thiol from sodium aurothiomalate was shown to be liberated in vivo and has been detected in the blood and urine of sodium aurothiomalate-treated patients. An increase in intracellular glutathione levels in response to treatment with sodium aurothiomalate and penicillamine was demonstrated and considered to be related to these drugs' properties as thiols. A pilot clinical trial using sodium thiomalate treatment demonstrated clinical improvement in four out of six patients after one course. Two patients relapsed but both improved after a second course and there were no serious adverse reactions. It is concluded that although larger controlled clinical trials are required, the role of gold in "chrysotherapy" must remain in question.
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The excretory fate and plasma level of thiomalate were studied after intramuscular administration of auro-14C-thiomalate to 3 patients with rheumatoid arthritis. The gold and the thiomalate parts separated in vivo, and the free thiomalate was excreted in the urine, rapidly at first and then slowly. After one day about 60% of the 14C-label had been recovered in the urine. The plasma level also declined rapidly. The results are in complete agreement with those previously described in animal experiments.
A search of the literature in this area shows that there is little national or international documentation available on the effect of physical activity on the development of disease in inflammatory rheumatic disorders. Low capacity for physical work has been demonstrated and is based on poor circulation and reduced muscle strength in rheumatism: several studies from Norway and elsewhere have documented the value of physical training, especially in improving the rheumatic patient's physical condition (1--2, 8). No investigations have been able to document any arrest of progress of the disease, but physical training seems to be able to maintain existing joint function and also to some extent prevent progressive deterioration in condition. There is therefore no disagreement about the significance of physiotherapy, but the intensity and duration of training are more controversial.
Human leukocyte proteins from more than 150 patients with rheumatoid arthritis, together with age- and sex-matched controls, were analyzed by use of the ISO-DALT technique in two-dimensional polyacrylamide gel electrophoresis. Patients with ankylosing spondylitis, polymyalgia rheumatica, psoriatic arthritis, calcium tendinitis, post-infectious arthritis, and asymmetrical seronegative arthritis were also included as positive controls. Synthesis of several proteins, referred to by number as members of the "Rheuma" set, is shown to increase in the leukocyte preparations from patients with classical rheumatoid arthritis. Several of these proteins are specific to monocytes or granulocytes; others are of unknown cellular origin, but appear to be unique to rheumatoid arthritis. The Rheuma proteins appear to be indicators of disease activity, because their increased synthesis can be correlated with sedimentation rate and other clinical indices of rheumatoid disease activity.
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Double isotope-labelled aurothiomalate (195Au-14C-thiomalate) has been administered to mice, and the excretory fate and tissue distribution have been studied. The results show that the gold and the thiomalate separate in vivo resulting in protein-bound gold and release of free thiomalate. About half of this thiol is excreted in the urine during the first day, and the remaining half is bound to tissue membranes and cells. Although thiomalate penetrates cellular membranes slowly in vitro. the compound is found in all organs, mostly in the liver and the kidneys, after administration of aurothiomalate. Separation of the gold moiety from its thiol carrier also takes place in man. This explains the finding of free thiomalate in the urine of patients receiving aurothiomalate intramuscularly. As thiomalate has now been shown to possess penicillamine-like biological activities it is suggested that at least part of the antirheumatic effects of aurothiomalate may be due to the thiol carrier being released in the body.
In order to study interactions in vivo between Au+ and SH-containing agents, groups of mice were given 35 mumol/kg of radiolabelled [195Au] thiomalate (Myocrisin) intramuscularly. The administration of Myocrisin is known to result in protein-bound gold and free thiomalate (mercaptosuccinate). High doses of dimercaptosuccinate (1 mmol/kg daily) increased the urinary excretion of radiolabelled gold [195Au] for several days. Treatment for 7 days with 1 mmol/kg of penicillamine or dimercaptosuccinate reduced the blood and kidney levels of gold to 30--50% of the controls. The oral administration of penicillamine in high doses, 1--10 mmol/kg, increased significantly the urinary excretion of [195Au] the first day after the Myocrisin injection, but on the subsequent days the radio-metal excretion was unaffected by the treatment. A lower dose level of penicillamine (0.3 mmol/kg daily) gave rise to only a small and insignificant increase in the urinary excretion of gold. The present results indicate that penicillamine at low clinical doses is an inefficient chelator of gold, while high doses (presumably comparable to about 1 200 mg daily in humans) may mobilize certain amounts of the metal deposits.
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Two young boys developed serious forms of dermatomyositis following BCG vaccination. Possibilities of a causal relationship between the disease and the vaccination are discussed. Extensive immunological tests, however, including in vitro stimulation of lymphocytes with PPD, gave no decisive evidence of abnormalities. It is concluded that in cases of dermatomyositis there is an absolute indication for a full anamnesis with regard to previous vaccination, to obtain clarification of the practical and theoretically important questions of a possible connection in this respect.
Double isotope-labelled auro thiomalate (Au195-C14-thiomalate) has been administered to mice and rats, and the excretory fate and tissue distribution have been studied. The results show that the gold and the thiomalate separate in vivo resulting in protein-bound gold and release of free thiomalate. About half of this thiol is excreted in the urine during the first day and the remaining half is taken up by the tissues. Thiomalate penetrates cellular membranes poorly, but is able to interact slowly with proteins (mixed disulphide formation). Part of the thiomalate which remains in the body is membrane bound. In contrast to penicillamine little thiomalate remains in circulation a few hours after administration. Gas chromatography--mass spectrometry has been used to search for the presence of free thiomalate in rheumatoid arthritis patients on Myocrisin (auro thiomalate) therapy. Thiomalate was found in their urine, but not in serum and synovial fluid 20 hours after administration. As thiomalate is released in the body after administration of Myocrisin. the question arises whether this thiol, like penicillamine, may have a beneficial effect in the treatment of rheumatoid arthritis.