Hypothesis
Auto-Immune Complications of D-Penicillamine—A Possible
Result of Zinc and Magnesium Depletion and of Pyridoxine
Inactivation
Mildred S. Seelig, MD, MPH, FACN
Department of Medicine, Goldwater Memorial Hospital, New York
University Medical Center; Roosevelt Island
Long-term high-dosage penicillamine treatment of patients with
advanced stages of diseases with autoimmune components has
resulted in very few adverse reactions in a series of over 50
such patients also given selected nutrients: pyridoxine, zinc and
magnesium (which penicillamine inactivates or chelates), and
vitamins B1 B12, and E (which have
sulfhydryl-protective activity). The patients on this regimen
have been essentially free of the side effects that occur in
about a third of patients treated with penicillamine without such
supplements. Reports of myasthenia gravis—a disease with
abnormalities of the thymus and of T-cells, as a side effect of
penicillamine—suggest that zinc, magnesium, and pyridoxine
might be the agents most likely to be protective. Pyridoxine is
necessary for cellular accumulation of zinc and magnesium
deficiencies of which have caused thymic and other immunologic
abnormalities. Whether the other vitamins administered contribute
to the favorable results requires further study.
Key words: autoimmune reactions, D-penicillamine,
immunology, magnesium, zinc, pyridoxine, thymus, T cells,
rheumatoid arthritis, Laennec cirrhosis
INTRODUCTlON
D-penicillamine's effect on immunoregulation [1,2] is
indicated by its activity against autoimmune diseases [3-5] and
its paradoxical production of immunologically mediated side
effects [1,2,5]. Depending on circumstances, it can either
inhibit or augment lymphocyte transformation in vitro [2]. The
development of myasthenia gravis during the course of
administration of D-penicillamine, rare though it is [6-10],
provides a clue to its immunologic toxicity. Thymic hyperplasia
[6] and abnormal thymus-dependent lymphocytes (T cells) [2] have
been reported in patients who developed this side effect. Similar
changes have been described in spontaneous myasthenia gravis
[11,12]. Thymic hyperplasia has also been seen in D-penicillamine
toxicology studies [13] The changes resemble those produced by
experimental magnesium or zinc depletion [14-19] and those found
in acrodermatitis enteropathica, a clinical zinc deficiency
disorder [20]. Because penicillamine chelates zinc and magnesium
[21] and because it inactivates pyridoxine [22], which is
necessary for cellular uptake of zinc and magnesium [23-25],
penicillamine's immunologic dysregulatory effects might be
partially mediated by interference with utilization of these
nutrients. In more than 50 patients with advanced chronic
diseases (with autoimmune components) who were given selected
nutrients before and during treatment with D-penicillamine in
high dosages for prolonged periods, there was a very low
incidence of adverse reactions [26-28]. We attribute this
predominantly to protection against drug-induced deficiencies of
magnesium, zinc, and pyridoxine.
METHODS
A combination of magnesium, zinc, and vitamins B6,
B1, B12, C, and E was given to patients
with Laennec cirrhosis (because of underlying deficiencies and
anticipated drug-induced losses) while awaiting approval for use
of D-penicillamine [28], This new application was to lower the
elevated copper levels of cirrhosis [29], to apply its effect on
collagen turnover [30] to hepatic fibrosis, and to treat the
autoimmune component of cirrhosis [4]. The supplements were given
orally three times a day with meals: vitamins B6 (50
mg), B1, (50 mg), B12 (25
µg), C (500 mg), and vitamin E (400 IU), zinc
(10-15 mg as the gluconate) and magnesium (100 mg as an amino
acid chelate). Magnesium sulfate (100 mg of Mg) was given
intramuscularly once a week to those with evidence of deficiency,
as determined by percentage retention of a test dose. Vitamin
B12 was also given intramuscularly, (2,000
µg) once a week because of its demonstrated
malabsorption in cirrhotic patients with pancreatic insufficiency
[28,31]. Partial improvement of iron-refractory anemia, strength,
and sense of well-being led us to continue the supplements when
D-penicillamine treatment was started (given at least 1 hour
apart from meals and supplements) 1-3 months after the nutrient
regimen had been started [28]. There was early response to 250-mg
and 500-mg daily doses of penicillamine for as long as 3 months
at each dosage level, but cessation of improvement led to
increase of dosage according to the accepted gradual incremental
regimen [5]. A few patients required increases to as much as 2.75
g/day to sustain improvement. The same regimen was utilized in
treatment of patients with multiple sclerosis in an attempt to
obtain benefit from its activity in autoimmune disease and from
its activity against neurotropic viruses [26], and with
rheumatoid arthritis with and without vasculitis (unpublished
observations) in order to obtain data with identical treatment
programs, Hospital staff shortages necessitated reduction in the
scope of our studies (in terms of number of patients and number
of daily doses given) after 5 years. Among those remaining in the
program, daily dosage was increased (in those whose dosage had
been reduced to 250-500 mg/day) when prior gains were not
sustained on lower doses. Patients given up to 500 mg of
penicillamine daily are usually given one-third the total daily
dosage of the supplements (at one meal). Several patients in
another study of rheumatoid arthritis, who were not on the
nutritional supplement program and who were intolerant of
penicillamine, had treatment cautiously restarted in combination
with only tocopherol (I.A. Jaffe, personal communication). In
addition to frequent evaluation for clinical changes, all
patients have been monitored at least monthly throughout the
treatment program for hematologic, urinary, and other side
effects.
RESULTS
The patients with Laennec cirrhosis, who received the full
therapeutic regimen, exhibited early correction of refractory
anemia and diminution of hepatic pain and enlargement in those
with concomitant hepatitis, as well as correction of inverted
albumin/globulin ratio and needle liver biopsy evidence of less
fibrosis [28]. Several of those with multiple sclerosis showed
decreased spasticity and improved vision, mobility, and
electroencephalograms during the full treatment phase of the
study [26], which subsequently plateaued and showed no further
improvement or some regression. A few with rheumatoid arthritis,
who have been more recently entered into the study, have shown
striking improvement. The improvement of the cirrhotic patients
was sustained only on doses of 1-2.0 g/day (or higher in a few),
with the exception of cirrhotic patients with encephalopathy or
peripheral neuropathy, whose neurologic signs improved markedly
on only 250 mg/day plus the nutrients. A patient with advanced
active rheumatoid arthritis, who had improved while receiving
1.75 g/day, suffered an exacerbation when her penicillamine
dosage was reduced to 250 mg/day. She showed gradual relief of
pain, lowering of sedimentation rate, and improvement in anemia
as the penicillamine dosage was gradually increased to (750
mg/day). Two, whose reactivation of advanced rheumatoid arthritis
was not controlled by corticoids, have similarly improved on
500-750 mg of D-penicillamine plus supplements. Another, with
severe rheumatoid arteritis and extensive necrosis of both legs,
improved remarkably, with re-epithelialzation and diminished
pain, as dosage was gradually increased to 1,250 mg daily (M.S.
Seelig and A.R. Berger, in preparation).
Among the more than 50 patients in this series, most of whom
were treated for 6 months to 7 years, only one or possibly two
serious side effects developed, and there were few transitory
discomforts [27]. Hematuria developed in one cirrhotic patient;
cystoscopy disclosed hemorrhagic cystitis. Since a renal biopsy
to rule out immunocomplex glomerulitis as a contributory factor
was refused, penicillamine treatment (but not the nutritional
supplements) was discontinued. The patient's signs of hepatic
dysfunction recurred in the hospital. He left, returned to drink,
and died in hepatic failure the following year. A multiple
sclerosis patient, with a history of anaphylaxis to penicillin,
developed frank albuminuria (1 g/day) while receiving 750 mg
penicillamine/day as an outpatient. Treatment was stopped, and he
was lost to further study. Several patients developed slight to
moderate proteinuria (1 + to 3 + ) at intervals, in association
with urinary tract infections. Proteinuria subsided when the
infection was controlled, without modification of penicillamine
therapy. Hemorrhagic bullae over elbows and ecchymoses over legs
and forearms developed in a cirrhotic patient while he was taking
2.75 g/day of penicillamine. The lesions cleared when the dosage
was reduced to 500 mg/day and did not recur when clinical
deterioration necessitated gradual increase of dosage to 1.75
g/day. Taste aberration or loss was encountered in two patients
in their first month of treatment, before zinc supplementation
had been started. Transitory rashes were encountered in only two
patients. No instance of thrombocytopenia or granulocytic
leukopenia has been seen. Low pretreatment thrombocyte counts (in
patients with Laennec cirrhosis or with multiple sclerosis), that
necessitated very cautious institution of penicillamine therapy
rose, during treatment. Low pretreatment hemoglobin and
hematocrit levels also rose.
The rheumatoid arthritis patients who had been intolerant of
D-penicillamine and had it restarted with tocopherol showed no
improvement in tolerance of penicillamine (I.A. Jaffe, personal
communication).
DISCUSSION
The unexpected occurrence of autoimmune disease complications
in patients being treated with D-penicillamine [5-10], a drug
with activity against autoimmune diseases [3-5, 10,26,28], has
led to many speculations and much study of its activity at the
lymphocytic level [2,10] to elucidate the disparate findings.
Thymic hyperplasia as a clinical [6] and experimental [13]
toxicologic development, and the thymic and lymphocytic changes
that are caused by depletion of two essential minerals namely,
zinc and magnesium [14-20] that penicillamine chelates [21],
suggest that the drug's first demonstrated clinical effect, as a
chelator [32], might be responsible for the most serious problems
associated with its use. Zinc is bound by penicillamine [21
,33,34], which can cause retention [33,34] or loss of zinc
[35,36], depending on whether it is given with or :separately
from the drug. Severe clinical manifestations of depletion
developed in a child being treated for Wilson disease [35], and
zinc levels were decreased in blood, brain, liver, and kidneys of
mice given D-penicillamine [36]. Magnesium is low in the order of
affinity of penicillamine for metals [21] .But possibly when
there is not an excess of trace or toxic minerals with greater
affinity for the drug, even this macro-mineral can be removed.
Preexistent magnesium inadequacy caused by cirrhosis or by drugs
(such as diuretics or corticoids) might be intensified by
penicillamine. The patients in this series have had marginally
low serum magnesium levels while receiving penicillamine and have
shown retention of most of parenterally administered test doses
of magnesium (which is suggestive of deficiency), even though
they all were being given magnesium supplements (100 mg three
times daily), and several had received weekly intramuscular
injections.
Inactivation of pyridoxine [22,36] has been demonstrated in
rheumatoid arthritis patients being treated with penicillamine
[22]; experimental vitamin B6 deficiency causes cellular losses
of both magnesium [23,24] and zinc [25], each of which is
necessary for pyridoxine-dependent enzymes [37-39]. Cellular loss
of magnesium and/or zinc might lead to aberrations of lymphoid
tissue. Magnesium deficiency in rats has caused thymic
hypertrophy [14-16] (or atrophy [16] under different conditions),
lymphosarcoma, and leukemia [15,40] in certain strains. In mice,
magnesium deficiency has reduced the number of
antibody-synthesizing cells, thereby lowering immunoglobulin
levels [39]. Optimal magnesium concentrations are required for
normal in vitro lymphocyte transformation [42]. In rats, zinc
deficiency causes inhibition of T-cell immunity [17], thymic
atrophy and hypofunction [18], and impaired cell-mediated
immunity [18]. Clinical zinc deficiency is associated with
immunodeficiencies and T-cell dysfunction in infants [19,20], and
thymic hypoplasia in calves [19,20] with acrodermatitis
enteropathica, a disease that results from impaired intestinal
zinc absorption [20,43,44]. The effect of simultaneous
deficiencies of magnesium, zinc, and pyridoxine, such as
penicillamine can cause, has not been explored in animal
models.
Few have investigated the effect of mineral supplements on the
therapeutic or adverse effects of D-penicillamine. A mixture of
minerals containing salts of magnesium, calcium, zinc, iron, and
cobalt has been recommended to avoid depletion of essential
minerals by the drug in Wilson disease patients [45]. The same
supplement was given schizophrenic patients treated with
penicillamine, with favorable results [46]. Improvement of
schizophrenia with penicillamine was not confirmed by others who
did not use the minerals [47]. It has been suggested that
schizophrenics who improved on penicillamine plus minerals might
have had pyroluria, a condition associated with zinc depletion,
or kryptopyroluria (mauve factor), which is characterized by
depletion of both zinc and pyridoxine and which improves somewhat
on their administration [48]. Mineral supplements have been found
to increase tolerance of high-dosage D-penicillamine in melanoma
patients [49; and H.B. Demopoulos, personal communication].
The nutritional supplements given to the patients in this
series [26-28] were selected to compensate for known
penicillamine interference (with pyridoxine [22] and zinc
[21,33-35]) and to substitute for the sulfhydryl-donor drug while
we were awaiting clearance for administration of the drug, since
increase in sulfhydryl levels might be a factor in therapeutic
response to D-penicillamine [32,50,51]. Sulfhydryl-protective
vitamins—B1 [52], B12 [53], E, and C
[54,55]—were given at first with the intent of
discontinuing them when penicillamine was started. A recent
hypothesis, that autoimmune disorders might be mediated by
free-radical-induced depression of T-cell suppressor function
[56], suggests that the antioxidant activity of these vitamins,
as well as that of D-penicillamine, might have played a role in
the patients' improvement.
Subjective and hematologic improvement occurred while the
patients were receiving the nutrients before penicillamine was
started. Because vitamin assays disclosed persistently low
levels, they were continued with penicillamine treatment. The
same regimen was employed when new patients entered the study
because of the absence of side effects, an incidence of 26-40% or
more having been expected on the basis of reports of others
[5,57,58]. Despite biochemical evidence of pyridoxine deficiency
in rheumatoid arthritis patients on long-term penicillamine
therapy [22], and of a disorder in pyridoxine metabolism in
rheumatoid patients not receiving penicillamine [59],
administration of only vitamin B6 with penicillamine
influenced neither the action of the drug nor its toxicity [5].
Zinc supplementation has corrected signs of severe zinc
deficiency in a patient receiving penicillamine for Wilson
disease [37], but its use has interfered with the therapeutic
effects of low-dosage penicillamine in rheumatoid arthritis
without preventing side effects [60]. In the present series,
larger doses of zinc (30-45 mg/day) have not interfered with the
therapeutic response to penicillamine in moderate to high doses
(1-2.75 g/day) in patients with cirrhosis [28] or rheumatoid
arthritis (unpublished observations).
Whether the vitamins that were provided in addition to
pyridoxine,—which with magnesium and zinc are probably the
most important components of the supplement mixture, contribute
to the low incidence of side effects remains to be ascertained.
Vitamin B1 and magnesium activities are interdependent
[61,62]. Magnesium deficiency intensifies some of the signs of
vitamin E deficiency [63]. Vitamin E, magnesium, and zinc are
each involved in maintaining membrane stability, and they and
other vitamins and minerals play roles in immunosurveillance
[64].
CONCLUSIONS
The most serious adverse reactions caused by D-penicillamine
are those that develop late and that reflect its dysregulation of
the immune system. The lack of such effects in a series of
patients given high-dosage penicillamine might be the result of
protecting against losses of cellular zinc and magnesium,
depletions of which are associated with thymic and T-cell
abnormalities.
ACKNOWLEDGMENTS
Appreciation is expressed to Herman Baker and Oscar Frank for
vitamin assays and to Israeli A. Jaffe for unpublished data and
for alerting me to the work demonstrating penicillamine's
immunodysregulatory effects.
REFERENCES
1. Dawkins RL, Zilko PJ: Editorial, Penicillamine: Friend or
foe? Austral N Zeal J Med 9:494-495, 1979.
2. Main RN, Roffe L: D-penicillamine and lymphocyte function
in rheumatoid arthritis: The inhibitory and augmenting effects of
D-penicillamine in vitro on phytohemagglutinin-induced
lymphocyte transformation. In Munthe E (ed): "Penicillamine
Research in Rheumatoid Disease." Oslo, Norway: Fabritius and
Sonner, 1976, pp 172-184.
3. Jaffe IA: Rheumatoid Arthritis with arteritis: Report of a
case treated with D-penicillamine. Ann Intern Med (61:556-563,
1964.
4. Epstein O. DeVilliers D, Jains S, Potter BJ, Thomas HC,
Sherlock C: Reduction of immune complexes and immunoglobins
induced by D-penicillamine in primary biliary cirrhosis. N Engl J
Med 300:274-278, 1979.
5. Jaffe A: Penicillamine treatment of rheumatoid arthritis.
Rationale, pattern of clinical response and clinical pharmacology
and toxicology. In Munthe E (ed): "Penicillamine Research in
Rheumatoid Disease." Oslo, Norway: Fabritius and Sonner. 1976, pp
11-24.
6. Bucknall RC, Dixon AJ, Glick EN, Woodland J, Zutshi DW:
Myasthenia gravis associated with penicillamine treatment of
rheumatoid arthritis. Br Med J 1:600-602, 1975.
7. Masters CL, Dawkins RI, Zilko PJ, Simpson JA. Leedman RJ,
Lindstrom J: Penicillamine associated myasthenia gravis
antiacetylcholine receptor and antistriational antibodies. Am J
Med 63:689-694, 1977.
8. Gordon RA, Burnside JW: D-penicillamine induced myasthenia
gravis in rheumatoid arthritis, Ann Intern Med 87:578-579,
1977.
9. Atcheson SG, Ward JR: Ptosis and weakness after start of
D-penicillamine therapy. Ann Intern Med 89:939-940, 1978.
10. Dawkins, RL, Garlepp M, McDonald BL, Williamson J, Zilko
PJ, Carrano J: Myasthenia gravis and penicillamine. J Rheumatol
8(Suppl 7):169-172, 1981.
11. Souadjian JV, Enriques P, Silverstein MN, et al: The
spectrum of diseases associated with thymoma. Coincidence or
syndrome? Arch Intern Med 134:374-379, 1974.
12. Richman DP, Patrick J, Arnason BGW: Cellular immunity in
myasthenia gravis. Response to purified acetylcholine receptor
and autologous thymocytes, N Engl J Med 294:694-698, 1976.
13. Jacobus DP, Bokelman DL, Majka JA: D-penicillamine in the
monkey. In Munthe E Ed: "Penicillamine Research in Rheumatoid
Disease." Oslo, Norway: Fabritius and Sonner, 1976, pp 25-40.
14. Hungerford GF, Karson EF: The eosinophilia of magnesium
deficiency. Blood 16:1642-1650, 1960.
15. Jasmin G: Lymphoedeme, hyperplasie et tumefaction du tissu
lymphatique chez le rat soumis a une diete deficiente en
magnesium. Rev Can Biol 22:383-390, 1963.
16. Alcock NW, Shils ME, Lieberman PH, Erlandson RA. Thymic
changes in the magnesium-depleted rat. Cancer Res 33:
2196-2204,1973.
17. Pekarck RS, Powanda MC, Hoagland AM: Effect of zinc
deficiency on the immune response of the rat. Fed Proc 36:360,
1977.
18. Chandra RK, Au B: Single nutrient deficiency and
cell-mediated immune responses.1. Zinc. Am J Clin Nutr
33:736-738, 1980.
19. Andresen E, Basse A, Brummerstedt E, Flagstad T. Zinc and
the immune system in cattle. Lancet 1:839-840, 1973.
20. Moynahan EJ: Zinc deficiency and cellular immune
deficiency in acro-dermatitis enteropathica in man and zinc
deficiency with thymic hypoplasia in Fresian calves: A possible
genetic link. Lancet 2:710, 1975.
21. Kuchinskas EJ, Rosen Y: Metal chelates of
DL-penicillamine. Arch Biochem Biophys 97:370-372, 1962.
22. Jaffe IA, Altman K, Merryman P: The antipyridoxine effect
of penicillamine in man. J Clin Invest 43:1869-1873, 1964.
23. Aikawa JK: Effects of pyridoxine and desoxypyridoxine on
magnesium metabolism in rabbits. Proc Soc Exp Biol Med
104:461-463, 1960.
24.. Durlach J: Donnees actuelles sur le mecanismes de
synergie entre vitamine B6 et magnesium. J Med
Besancon 5:349-359, 1969.
25. Hsu JM: Zinc content in tissues of pyridoxine deficient
rats. Proc Soc Exp Biol Med 119:177-180, 1965.
26. Seelig MS, Alba A, Berger AR, Rudez A, Tarlau M: Pilot
study of D-penicillamine, vitamins and minerals in multiple
sclerosis. J Clin Psychiatry 39: 170-174, 1978.
27. Seelig MS, Berger AR: Do trace elemems, magnesium and
antioxidants protect against D-penicillamine toxicity? In
Hemphill DD (ed): "Trace Substances in Environmental Health. A
Symposium." Columbia, Mo: University of Missouri, 1977, Vol 11,
pp 243-251.
28. Seelig MS, Berger AR , Hazzi C, Milstoc M: Long term pilot
study of D-penicillamine minerals and vitamins in patients with
advanced Laennec's cirrhosis, In Hemphill DD (ed): "Trace
Substances in Environmental Health. A Symposium." Columbia, Mo:
University of Missouri, 1979, Vol 13, pp 389-400.
29. Butt EM, Nusbaum RE, Gilmour TC, DiDio SL: Trace metal
patterns in disease states, Am J Clin Pathol 26:225-242,
1956.
30, Harkness RD: In vitro and in vivo observations on the
effect of penicillamine on collagen. Postgrad Med J 44:31-34,
1968.
31. Matuchansky C, Rambaud R, Modigliani R, Bernier JJ:
Vitamin B12 malabsorption in chronic pancreatitis.
Gasterenterology 67: 406-407, 1974.
32. Walshe JM: Penicillamine, a new oral therapy for Wilson's
disease. Am J Med 21:487-495, 1956.
33. McCall JT, Goldstein NP, Randall RV, Gross JB: Comparative
metabolism of copper and zinc in patients with Wilson's disease
(hepatolenticular degeneration). Am J Med Sci 254:13-23,
1967.
34. Aaseth J, Forre O, Munthe E, Froland SS, Abrahamsen T:
Biological aspects of metal chelation during penicillamine
treatment. In Munthe E (ed): Penicillamine Research in Rheumatoid
Disease." Oslo, Norway: Fabritius and Sonner, 1976, pp 80-87.
35. Klingberg WG, Prasad AS, Oberleas D: Zinc deficiency
following penicillamine therapy. In Prasad AS (ed): "Trace
Elements in Human Health and Disease," New York: Academic Press,
1976, pp 51-65.
36. Kuchinskas EJ, Horvath A, Duvigneaud V: On anti-vitamin
B6 effect of l-penicillamine. Arch Biochem Biophys
68:68-75,1957.
37. Lehninger AL: Role of metal ions in enzyme systems.
Physiol Rev 30:393-429, 1950.
38. McCormick DB, Gregory ME, Snell EE: Pyridoxal
phosphokinases. 1. Assay, distribution, purification and
properties, J Biol Chem 236:2076-2084, 1961.
39. Heaton FW: : Magnesium in intermediary metabolism, In
Cantin M, Seelig MS (eds): "Magnesium in Health and Disease."
Jamaica, New York: SP Medical and Scientific Books, 1980, pp
43-55.
40. Hass GM, McCreary PA, Laing GH: Lymphoproliferative and
immunologic aspects of magnesium deficiency. In Cantin M, Seelig
MS (eds): "Magnesium in Health and Disease." Jamaica, New York:
SP Medical and Scientific Books, 1980, pp 185-200.
41. Elin RJ, The effect of magnesium deficiency in mice on
serum immunoglobulin concentrations and antibody plaque-forming
cells. Proc Exp Soc Biol Med 148:620-624, 1975.
42. Brennan JK, Lichtman MA: The effect of extracellular
calcium and magnesium on the proliferation of murine
lymphoblasts. J Cell Physiol 82:101-112,1973.
43. Moynahan EJ: Acrodermatitis enteropathica. A lethal
inherited human zinc-deficiency disorder, Lancet 2:399, 1974,
44. Hambidge KM, Neldner KH, Walravens PA. Zinc and
acrodermatitis enteropathica. In Hambridge KM, Nichols BM (eds):
"Zinc and Copper in Clinical Medicine," Jamaica, New York: SIP
Medical and Scientific Books, 1976, pp 81-98,
45. Fister WP, Boulding JE, Baker RA: The treatment of
hepatolenticular degeneration with penicillamine, with re:port of
two cases. Can Med Assoc J 78:99-102, 1958.
46. Nicolson GA, Greiner AC, McFarlane WJ, Barker A: Effect of
penicillamine on schizophrenia patients. Lancet 1:344-347,
1966.
47. Brooker BK, Papeschi R, Murray L: Negative results of a
trial of penicillamine in chronic schizophrenia. Postgrad Med J
44(Oct Suppl): 48-52, 1968.
48. Pfeiffer CC, Bacchi D: Copper, zinc, manganese, niacin and
pyridoxine in the schizophrenias. J Appl Nutr 27:9-39, 1975.
49. Demopoulos HB: Effects of reducing the
phenylalanine-tyrosine intake of patients with advanced malignant
melanoma. Cancer 19: 657-664, 1966.
50. Lorber A, Chang C, Masuoka D, Meacham, I: Effect of thiols
in biological systems on protein sulfhydryl content. Biochem
Pharmacol 19:1551-1560, 1970.
51.Munthe E, Guldal G, Jellum E: Increased intracellular
glutathione during penicillamine treatment for rheumatoid
arthritis. Lancet 2:1126-1127, 1979.
52. Kochetov GA, Lutovinova GF: Sulfhydryl groups and
transketolase activity. Biochem Biophys Res Commun 22:129-134,
1966.
53. Register UD: Effect of vitamin B12 on liver and
blood non-protein sulphydryl compounds. J Biol Chem 206:705-709,
1953.
54. Schwarz K: Vitamin E, trace elements and sulfhydryl groups
in respiratory decline. Vitamins Hormones 20:463-484, 1962.
55. Tappel AL: Vitamin E as the biological lipid antioxidant.
Vitamins Hormones 20:493-510, 1962.
56. Harman D: Free radical theory of aging: : Beneficial
effect of antioxidants on the life span of male NZB mice; role of
free radical reactions in the deterioration of the immune system
with age and in the pathogenesis of systemic lupus erythematosis,
Age 3:64-73, 1980.
57. Stein HB, Patterson AC, Offer RA: Adverse effects of
D-penicillamine in rheumatoid arthritis. Ann Intern Med 92:24-29,
1980.
58. Halverson PB, Kozin F, Bernhard GA, Goldman AL: Toxicity
of penicillamine. A serious limitation to therapy in rheumatoid
arthritis. J Am Med Assoc 240:1870-1871, 1978..
59. Bett IM: Effect of pyridoxine on tryptophan metabolism in
rheumatoid arthritis. Ann Rheum Dis 21:388-391, 1962.
60. Mery C, Delrieu F, Ghozlan R, Saporta L, Simon F, Amor B,
Menkes CJ, Delbarre F: Controlled trial of D-penicillamine in
rheumatoid arthritis. Dose effect and the role of zinc. Scand J
Rheumatol 5:241-247, 1976.
61. Itokawa Y, Inoue K, Natori Y, Okazaki K, Fujiwara M:
Effect of thiamine on growth, tissue magnesium, thiamine levels
and transketolase activity in magnesium deficient rats. J Nutr
Sci Vitaminol 18:159-164, 1972.
62. Itokawa Y, Tseng LF, Fujiwara U: Thiamine metabolism in
magnesium-deficient rats. J Nutr Sci Vitaminol 20:249-255,
1974.
63. Goldsmith LA: Relative magnesium deficiency in the rat. J
Nutr 73:87-102,1967.
64. Seelig MS: Magnesium (and trace substance) deficiencies in
the pathogenesis of cancer. Biol Trace Elem Res 1:273-297,
1979.
Received December, 1981; accepted February, 1982.
Journal of the American College of Nutrition 1:207-214
(1982)
Address reprint requests to Dr. Mildred S, Seelig,
Department of Medicine, Goldwater Memorial Hospital, New York
University Medical Center, Roosevelt Island, New York NY
10044. Deceased.
This page was first uploaded to The Magnesium Web Site on July
31, 2007
http://www.mgwater.com/
Healthy Water
Association--USA