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Forty-four patients with definite or classic rheumatoid arthritis and failure to tolerate or respond to gold therapy were treated with D-penicillamine on a so-called go-slow, go-low regime. Seventeen patients tolerated the drug and had a 3-13 month follow-up assessment; 8 were markedly improved, 6 moderately or slightly improved, and 3 unimproved. Penicillamine had to be discontinued in 9 patients because of toxic side effects.Since the first report of Jaffe ( I ) , the therapeutic efficacy of D-penicillamine in the treatment of active rheumatoid arthritis (RA) has been supported in various centers with both controlled (2) and uncontrolled (3-6) studies. The toxicity of D-penicillamine has also been defined (7). However, with the so-called go-slow, go-low regimen (8,9), the incidence of toxicity has been reduced while the therapeutic efficacy has been maintained. At the Arthritis Centre in Vancouver, British Columbia, between April 1975 and June 1976, 44 patients with R A were treated with D-penicillamine. The purpose of this paper is to report that experience with special reference both to toxicity in the 44 patients and to the therapeutic effectiveness in 17 patients followed more than 3 months. I n view of the consensus in England regarding the therapeutic efficacy (2,7,9), a randomized comparison was considered inappropriate. MATERIALS AND METHODSPatients. Every patient had definite or classic adult rheumatoid arthritis by A R A criteria (10); 25 were women and 19 were men. They were all under supervision by one of the consulting rheumatologists at the Centre, who was responsible for the Penicillamine Clinic. The patients all had active disease, despite adherence to the basic regime for R A . All patients had received chrysotherapy in the past, but the gold treatment was discontinued in 37 patients because of side effects and in 7 patients because of failure to respond. At the start of the study all patients had clinical and laboratory evidence of active disease.Treatment Schedule. All patients began treatment with 250 mg of D-penicillamine (Merck, Sharp and Dohrne) daily. given orally after meals. The dose was increased by adding 250 mg to the daily dose every 2 weeks early in the study, and every 4 weeks later in the study. A maintenance dose of 500-750 rng/day in divided dosage was generally achieved in 12-16 weeks. A higher daily dosage was given in exceptional cases. but the dose was reduced to 750 mg daily as soon as clinical improvement took place. Nonsteroidal anti-

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