Best treatment of rheumatic fever-rule of 3

ACUTE RHEUMATIC FEVER TREATMENT

All acute rheumatic fever patients should be put on bed rest and closely watched for signs of carditis. As soon as the symptoms of acute inflammation have faded, they can be allowed to walk. Patients with carditis, however, need to be in bed for longer periods of time.

 When to start Antibiotic Therapy?

In order to guarantee that GAS has been completely eradicated from the upper respiratory tract, the patient should receive 10 days of oral penicillin or amoxicillin therapy or a single intramuscular injection of benzathine penicillin once the diagnosis has been made, regardless of the findings of the throat culture.

If penicillin-allergic, 10 days of erythromycin, azithromycin (5 days) or clindamycin is indicated.

After this initial course of antibiotic therapy, long-term antibiotic prophylaxis should be instituted.

Chemoprophylaxis for Recurrences of Acute Rheumatic Fever (Secondary Prophylaxis)

DRUG

Penicillin G benzathine

DOSE-600,000 IU for children weighing ≤60 lb and 1.2 million IU for children weighing >60 lb, Intramuscular every 4 wk* (In high-risk situations, administration every 3 wk is recommended)

OR

Penicillin V 250 mg, twice a day  Orally

or

Sulfadiazine or sulfisoxazole

Dose- 0.5 g, once a day for Oral for patients weighing ≤60 lb and 1.0 g, once a day for patients weighing >60 lb

 FOR PEOPLE WHO ARE ALLERGIC TO PENICILLIN AND SULFONAMIDE DRUGS

Macrolide or azalide

Dose -Variable

Duration of Prophylaxis for People Who Have Had Acute Rheumatic Fever:

Recommendations of the American Heart Association

CATEGORY

1)Rheumatic fever without carditis

DURATION-   5 yr or until 21 yr of age,whichever is longer

2) Rheumatic fever with carditis but without residual heart disease (no valvular disease

DURATION-   10 yr or until 21 yr of age, whichever is longer

3) Rheumatic fever with carditis and residual heart disease (persistent valvular disease*)

DURATION- 10 yr or until 40 yr of age, whichever is longer; sometimes lifelong prophylaxis

When to start Antiinflammatory Therapy ?

Antiinflammatory agents (e.g., salicylates, corticosteroids) should not be used for  arthralgia or atypical arthritis . Acute rheumatic fever may be difficult to diagnose if one of these medications is used prematurely as it may prevent the development of the distinctive migrating polyarthritis. Acetaminophen can be used to control pain and fever while the patient is being observed for more definite signs of acute rheumatic fever or for evidence of another disease.

Indication of aspirin

If Patients is having typical migratory polyarthritis

Patients with carditis without cardiomegaly or congestive heart failure.

The  dose of aspirin is 50-70 mg/kg/day in 4 divided doses PO for 3 days, followed by 50 mg/kg/day in 4 divided doses PO for 3 wk and half that dose for another 3 wk.

Serum salicylate level estimation  is not necessary unless the arthritis does not respond or signs of salicylate toxicity (tinnitus, hyperventilation) develop. There is no other  nonsteroidal antiinflammatory agents have better effect than salicylates.

When to start corticosteroids?        

Patients with carditis and more than minimal cardiomegaly and/or congestive heart failure

The usual dose of prednisone is 2 mg/kg/day in 4 divided doses for 3 wk followed by half the dose for 3 wk and then tapering of the dose by 5 mg/24 hr every 3 days.

When prednisone is being tapered, aspirin should be started at 50 mg/kg/day in 4 divided doses for 6 wk to prevent rebound of inflammation.

Supportive therapies for patients with moderate to severe carditis include digoxin, fluid and salt restriction, diuretics, and oxygen.

The cardiac toxicity of digoxin is enhanced with myocarditis.The recurrence of clinical symptoms or an increase in erythrocyte sedimentation rate and C-reactive protein (rebound) may occur after stopping the anti-inflammatory therapy. Salicylates or steroids may need to be increased until near-normalization is reached.

Sydenham Chorea

Chorea often occurs as an isolated manifestation or when after the acute phase of the disease subsided.So, antiinflammatory agents are usually not indicated.Sedatives can be given during early course of chorea.Phenobarbital (16-32 mg every 6-8 hr PO) is the drug of choice. If phenobarbital is ineffective, then haloperidol (0.01-0.03 mg/ kg/24 hr divided bid PO) or chlorpromazine (0.5 mg/kg every 4-6 hr PO) should be tried. Few  patients may get benefit from a few week course of corticosteroids .