Drug Treatment,Management for Rheumatic Fever/RF & Rheumatic Heart Disease

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

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Results

RHEUMATIC FEVER AND RHEUMATIC HEART DISEASE (RF/RHD)

Related topics

Predisposing Factors and Pathogenesis of RF/RHD

Clinical Features-Major and Other Manifestations of RF/RHD

Laboratory Investigations and Differential Diagnosis of RF/RHD

Prognosis Sequelae and Cardiac Lesion Progression for RF/RHD

Prevention and Advise During Follow Up for RF/RHD

Dr J. R. Kamat
Professor of Pediatrics
Head of Department of Pediatrics
KEM Hospital

Treatment :

I) General Management

Bed rest : Daily evaluation for CCF is required which may occur in the first 2-3 weeks.

Table II : Bed Rest and Ambulatory period:

Status	Bed rest	Gradual ambulation
No carditis	2 weeks	2 weeks
Carditis without cardiomegaly	4 weeks	4 weeks
Carditis with cardiomegaly	6 weeks	4 weeks
Carditis with CCF	Till heart failure present	3 months

Monitor Basal Pulse rate daily & ESR every week.

II. Drug treatment :

Antimicrobial: Anti-streptococcal drug treatment is required to eradicate streptococci present in the throat -
- Oral penicillin for 10 days or
- Benzathine penicillin 1.2 mega units I/M or
- Erythromycin 20-40 mg/ kg/d for 10 days.
Start longterm benzathine penicillin prophylaxis
Analgesic / anti-inflammatory: Till diagnosis is confirmed give only paracetamol.
- For arthritis and carditis without cardiomegaly
  - Aspirin 100 mg/ kg/day (max 6 gm/d) for 2 weeks. Then 75 mg/kg/day for 2-6 weeks.
  Watch for salicylism - Tinnitus + hyperapnea
  
  Avoid gastritis by giving the drug with milk & give antacids.
- For carditis with cardiomegaly or CCF
  - Prednisolone 2 mg/ kg /day (Max. 80 mg/d) x 2-3 weeks and taper over 2-3 weeks (decrease by 5 mg every 2-3 days)
  - Start aspirin 75 mg/kg/day after 2 weeks when tapering of steroid is started and continue for 6 weeks after Prednisolone is stopped.
  - In very acute and severe cases IV methyl Prednisolone (10-40 mg/kg) is given followed by Prednisolone and aspirin as above.
  *Overlap therapy of steroids with aspirin reduces the post-therapeutic rebound.
  
  *Longterm benefit of steroids over aspirin therapy is debatable as there is no difference in the residual heart disease, however the benefits are:-
  - Patients tolerate steroids better than aspirin.
  - CCF is controlled faster.
  - Deaths during acute episode are reduced.
  *Termination of anti-inflammatory drug may be followed by laboratory abnormalities "lab rebound " - this does not require any treatment.
  
  * Weekly follow up of ESR is done to note recovery from Rheumatic activity. CRP is a better and a more reliable index. Once ESR remains normal for 2 months, a recurrence is possible only after a fresh streptococcal infection. In 5-10% of patients, a raised ESR may persist for months.
  
  This benign unexplained phenomenon does not warrant any change in treatment.
Diuretics: If bed rest and steroids do not control CCF, add diuretic and digoxin. Use digoxin with caution because of its low therapeutic index in patients with carditis.
Treatment of chorea : Bed rest is required only for severe attacks to prevent injury. Anti-inflammatory drugs are is not indicated in isolated chorea.

Sedation is helpful in early disease - phenobarbitone 15-30 mg Q 6-8 hrs.
If ineffective Haloperidol 0.01- 0.03 mg/kg / day in 2 doses
or
Chlorpromazine 0.5 mg/kg Q 4-6 hrs can be given.
Medication is given till chorea is controlled and is gradually omitted.

Next : Prognosis Sequelae and Cardiac Lesion Progression of RF/RHD

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