The studies surely show that intramuscular is more effective, but it also seems to be more toxic. It causes rashes, stomatitis, proteinuria, leukopenia, people need very frequent monitoring of CBC s, urinalyses, to look for this kind of involvement. Oral gold salts cause more of a diarrhea problem. The problem of Anti-malarials, hydroxychloroquine, I happen to be a fan of hydroxychloroquine particularly in milder disease. A certain percentage of people do really well with hydroxychloroquine or Plaquenil.
Rashes are occasionally a problem.
They can be pretty ugly rashes and they do require D-penicillamine. I think I ve written one prescription for D-penicillamine in my life. It was a patient who was already on D-penicillamine when I met her. D-penicillamine has a lot of toxicities and more rheumatologist don't use it anymore, although occasionally you can see it. Methotrexate is obviously the mainstay of treatment in RA at this point.