Rheumatic fever medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Lance Christiansen, D.O.; Associate Editor(s)-in-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Treatment

The management of acute rheumatic fever is geared toward the reduction of inflammation with anti-inflammatory medications such as aspirin or corticosteroids. Individuals with positive cultures for strep throat should also be treated with antibiotics. Another important cornerstone in treating rheumatic fever includes the continuous use of low dose antibiotics (such as penicillin, sulfadiazine, or erythromycin) to prevent recurrence.

Infection

Patients with positive cultures for streptococcus pyogenes should be treated with penicillin as long as allergy is not present. This treatment will not alter the course of the acute disease.

Inflammation

Patients with significant symptoms may require corticosteroids. Salicylates are useful for pain.

Heart failure

Some patients develop significant carditis which manifests as congestive heart failure. This requires the usual treatment for heart failure: diuretics and digoxin. Unlike normal heart failure, rheumatic heart failure responds well to corticosteroids.

National Heart Foundation of Australia and the Cardiac Society of Australia and New Zealand Treatment Guidelines

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All cases Single dose intramuscular benzathine penicillin G (preferable) or oral penicillin V for 10 days (intravenous penicillin not needed; oral erythromycin may be used if patient allergic to penicillin) Arthritis and fever Paracetamol (first-line) or codeine until diagnosis confirmed Aspirin (first-line) or naproxen once diagnosis confirmed, if arthritis or severe arthralgia present Mild arthralgia and fever may respond to paracetamol alone Influenza vaccine for children receiving aspirin during the influenza season (autumn/winter) Chorea No treatment for most cases Carbamazepine or valproic acid if treatment is necessary Carditis/heart failure Bed-rest Urgent echocardiogram Anti-heart failure medication Diuretics/fluid restriction for mild to moderate heart failure ACE inhibitors for more severe heart failure, particularly if aortic regurgitation present Glucocorticoids optional for severe carditis (consider treating for possible opportunistic infections) Digoxin if atrial fibrillation present Valve surgery for life-threatening acute carditis (rare) Long-term preventive measures Give first dose of secondary prophylaxis Notify case for recording in ARF/RHD register, if available Contact local health staff to ensure follow-up Provide culturally appropriate education to patient and family Arrange dental review and ongoing dental care to reduce risk of endocarditis

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