DMARD (oral gold compound) Pregnancy: Contraindicated — animal teratogenicity; gold crosses placenta and concentrates in fetal tissues.

Auranofin

Brand names: Ridaura

Adult dose

Dose: 6 mg/day in 1–2 divided doses for 4–6 months. If responding, continue 6 mg OD; if no response after 6 months, increase to 9 mg/day in 3 divided doses for further 3 months — discontinue if still ineffective.

Route: Oral

Frequency: Once or twice daily

Max: 9 mg/day

Specialist initiation only (rheumatology). Slow onset of action — clinical response typically at 3–6 months.

Dose adjustments

Renal

Avoid in significant renal impairment (proteinuria risk).

Hepatic

Avoid in severe hepatic impairment.

Clinical pearls

Largely superseded by methotrexate, leflunomide, and biologic DMARDs — UK use now extremely rare; reserved for cases of refractory or contraindication to standard DMARDs (e.g., palindromic RA, isolated specialist preference).
Parenteral gold (sodium aurothiomalate / Myocrisin) discontinued in UK 2014 — auranofin is the only remaining gold preparation.
Stop and refer urgently if mouth ulcers (often heralds skin/mucous reaction), proteinuria >0.3 g/24h, platelet <100, or unexplained eosinophilia.
FBC, U&Es, urinalysis, and LFTs at baseline then monthly — never extend monitoring intervals.
Counsel about insidious dyspnoea — gold pulmonary toxicity may present as new-onset cough.

Contraindications

Severe blood dyscrasias
Severe renal impairment, recent proteinuria, glomerulonephritis
Severe hepatic impairment, history of cholestatic jaundice
Systemic lupus erythematosus
Exfoliative dermatitis, severe eczema
Necrotising enterocolitis, history of pulmonary fibrosis
Pregnancy and breastfeeding
Hypersensitivity to gold or chrysotherapy

Side effects

Diarrhoea (very common — dose-limiting in 30–50%)
Pruritus, rash (often pre-stomatitis warning sign)
Stomatitis, glossitis, metallic taste
Proteinuria (membranous glomerulonephritis — stop if >0.3 g/24h)
Thrombocytopenia, neutropenia, aplastic anaemia (rare but serious)
Hepatotoxicity, cholestatic jaundice
Pulmonary fibrosis / interstitial pneumonitis
Peripheral neuropathy (rare)
Alopecia, conjunctivitis

Interactions

Phenytoin: ↑ phenytoin levels
Penicillamine: additive haematological / renal toxicity — avoid
Other DMARDs (methotrexate, leflunomide): no clear additive toxicity but specialist judgement
ACEi: nitritoid reaction reported (flushing, hypotension) historically with parenteral gold; less concern with oral auranofin

Monitoring

FBC monthly
U&Es and urinalysis monthly
LFTs monthly
CXR if respiratory symptoms
Patient self-monitoring: mouth ulcers, rash, easy bruising, breathlessness — report immediately

Reference: BNF 90; SmPC Ridaura; BSR Rheumatoid Arthritis Guideline 2018; EULAR RA Management 2022. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways