Monitor for side effects especially agranulocytosis which may present with sore throat or fever
- Immunomodulatory and Chelating effects
- Rarely used nowadays as a DMARD in rheumatoid disease
Action
- Chelating agent via its sulphydryl group - copper and lead, cystine
- Immunomodulatory effects - Macrophage activity / altered gene expression
- Forms a soluble disulphide compound with cystine
Indications
- Rheumatoid diseases as a DMARD
- Chelating agent in Wilson's disease (Hepatolenticular degeneration)
- Chelating agent in Cystinuria
- Chelating agent in Heavy metal poisoning
Interactions
- Absorption reduced by oral Iron
Cautions
- Fever, sore throat check WCC
- Petechiae, bleeds check platelets
- Weakness, Diplopia - Myasthenia Gravis
- Check U&E and urinalysis
Contraindications
- There is some shared allergy with Penicillin so avoid in patients with documented Penicillin allergy
- SLE, Pregnancy, Renal impairment - Renally excreted
Side effects
- Skin rashes - early are morbilliform - can also cause pemphigoid type rash after 6 months
- Taste disturbance, Proteinuria and Immune complex nephritis
- Goodpasture's like syndrome, Nephrotic syndrome
- Marrow toxicity - low neutrophils and platelets
- Develop Antinuclear antibodies, Drug-induced Lupus syndrome
- Myasthenia Gravis with autoantibodies, Aplastic and haemolytic anaemia
- Severe Exfoliative dermatitis with some other DMARDS e.g. gold, chloroquine
Dose
- Penicillamine 125-2000 mg once daily with reduced dose in renal failure or elderly. Clinical response takes 6-12 weeks in rheumatoid arthritis
- Regular blood and urine tests needed
- May require Pyridoxine supplementation
References