Rheumatic%20fever%20-%20acute Treatment

Goals of Therapy

• Provide education for patient and patient’s caregivers
• Eradication of group A beta-hemolytic Streptococcus (GAS)
• Symptomatic relief of acute manifestations of ARF
  • Anti-inflammatory drugs is the mainstay for symptomatic management of ARF-associated arthritis and usually continued until all joint symptoms have resolved
  • Management of rheumatic carditis involves early diagnosis and severity assessment with echocardiography, management of heart failure and other complications
  • Prevention of progression of cardiac disease by providing prophylaxis against future GAS infection

Pharmacotherapy

• Give oral Phenoxymethylpenicillin upon suspicion of acute rheumatic fever (ARF) and during the course of diagnosis. Once diagnosis is established, administer Benzathine penicillin G and stop Phenoxymethylpenicillin

Secondary Prevention
Recurrent ARF is defined as 2 major or 1 major with 2 minor or 3 minor manifestations (patients with moderate- to high-risk) plus evidence of previous GAS infection

• Continuous antimicrobial prophylaxis is recommended in patients with history of rheumatic fever (RF)
• Prophylaxis of 12 months duration with reevaluation thereafter is recommended for patients with possible RF
  • Reevaluation should include repeat history, physical exam and echocardiography

Amoxicillin

• Used to eradicate or prevent Group A streptococcus (GAS) infection
• Treatment option for patients with penicillin allergy

Benzathine Penicillin G

• Given to eradicate streptococci and is the 1st dose of penicillin for secondary prophylaxis
• Drug of choice for acute rheumatic fever (ARF) patients with confirmed GAS not allergic to Penicillin

Cephalosporins

• Eg Cephalexin, Cefadroxil
• Used for the primary prevention and treatment of GAS infection in patients allergic to Penicillin

Macrolides (Oral)

• Eg Erythromycin, Clindamycin, Clarithromycin, Azithromycin, Roxithromycin
• Used if patient has documented penicillin allergy
• Recommended once there is suspicion of ARF and continue for 10 days or until ARF is diagnosed and Benzathine penicillin G is administered

Phenoxymethylpenicillin (Penicillin V) (Oral)

• Used to eradicate GAS infection, if present
• Start administration once there is suspicion of ARF and continue for 10 days or until ARF is diagnosed and Benzathine penicillin G is administered

Symptomatic Pharmacotherapy

Rheumatologists, cardiologists, and/or neurologists should be consulted based on the patient’s symptoms. Use of NSAIDs, salicylates and/or steroids are not recommended until ARF is confirmed as it will prevent development of joint manifestations and suppress acute phase reactants

Arthritis

• Salicylates and nonsteroidal anti-inflammatory drugs (NSAID)
  • Eg Aspirin, Codeine, Ibuprofen, Naproxen, Paracetamol
  • Used for arthritis or severe arthralgia
  • Paracetamol is recommended as first-line therapy for ARF arthritis pain
  • Naproxen is a treatment option for Aspirin
  • Recommended once ARF is confirmed 

• Analgesics
  • Paracetamol and codeine are used for arthritis or severe arthralgia if ARF is not yet confirmed and patient is still undergoing diagnosis
  • Patients with mild arthralgia respond well to Paracetamol
• Low-dose glucocorticoids may only be considered in patients unresponsive to 1st-line agents

Carditis/Heart Failure

• Diuretics (eg Furosemide, Spironolactone) are used for mild-moderate heart failure
• Angiotensin-converting enzyme (ACE) inhibitors (eg Captopril, Enalapril, Lisinopril) may be used for more severe heart failure [dysfunctional left ventricular (LV) function]
• Corticosteroids (eg Prednisone, Prednisolone) are indicated for severe carditis, heart failure, or pericarditis with effusion
• Digoxin is administered if atrial fibrillation or heart failure is present
• Please see Heart Failure - Acute and Heart Failure - Chronic disease management charts in MIMS Cardiology for further information

Sydenham’s Chorea

• Start pharmacotherapy when symptoms interfere with normal activities
  • Sedatives or anticonvulsants (eg Carbamazepine, Valproic Acid, Haloperidol, Chlorpromazine and Diazepam) may be used to relieve symptoms

Fever

• Paracetamol is indicated for fever

• Recommended 1st-line antibiotic regimen for the prevention of recurrent RF
• An intramuscular dose every 4 weeks is recommended

Oral Anti-infectives

Phenoxymethylpenicillin

• The only oral anti-infective recommended for the prevention of recurrent RF
• 2nd-line antibiotic regimen for the prevention of ARF next to Penicillin G

Sulfadiazine or Sulfafurazole

• Recommended only in patients allergic to penicillins

Macrolides

• Erythromycin, Clarithromycin, or Azithromycin may be used in patients allergic to penicillins, Sulfadiazine, and Sulfafurazole

Duration of Prophylaxis

• RF patients with persistent valvular disease should receive prophylaxis for 10 years or until 40 years old, whichever is longer
  • Lifelong prophylaxis may be recommended in high-risk patients
• RF patients with carditis but no residual heart disease may receive prophylaxis for 10 years or until 21 years old, whichever is longer
• RF patients without carditis may continue prophylaxis up to 5 years or until 21 years old, whichever is longer
• Discontinuation of prophylaxis should be thoroughly discussed with the patient and his/her family with emphasis on risks vs benefits

General care

• Examine daily for pattern of arthritis, presence of heart murmur, choreiform movements, skin rash and subcutaneous nodules
• Seek medical attention upon the 1st sign of pharyngitis
• Document cardiac signs and symptoms with carditis
• Educate and involve family members

• Advise nutritious diet without restrictions except in patients with congestive heart failure (CHF)
  • Patients with CHF should follow a fluid-limited and sodium-restricted diet
• Potassium supplementation may be necessary due to mineralocorticoid effect of corticosteroid and diuretics, if used

Bed Rest and Indoor Ambulation

• Recommended duration of bed rest
  • 1-2 weeks with arthritis alone
  • 2-3 weeks with mild carditis, 4-6 weeks with moderate carditis, 2-4 months with severe carditis
• Recommended duration of indoor ambulation
  • 1-2 weeks after hospital discharge with arthritis alone
  • 2-3 weeks after hospital discharge with mild carditis, 4-6 weeks after hospital discharge with moderate carditis, 2-4 months after hospital discharge with severe carditis
• Do not allow full activity until the C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) have returned to normal
• Patients with Sydenham’s chorea may require a wheelchair and should be on homebound instruction until abnormal movements resolve
• No physical restrictions are needed after the initial episode subsides in the absence of carditis