What is the management of Rheumatic Fever (Acute Rheumatic Fever)?

From the Guidelines

The management of Rheumatic Fever (Acute Rheumatic Fever) involves a multi-faceted approach, with the primary goal of eradicating the streptococcal infection and preventing recurrence, as outlined in the 2021 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Key Components of Management

• Eradicate the streptococcal infection with a single intramuscular injection of benzathine penicillin G (1.2 million units for adults, 600,000 units for children under 27 kg) or alternative antibiotics for penicillin-allergic patients, such as erythromycin or oral cephalosporin, as recommended by the American Heart Association 1.
• Manage inflammation and symptoms with aspirin (80-100 mg/kg/day in 4 divided doses) for 2-4 weeks, then taper over 2-3 weeks, or prednisone (2 mg/kg/day) for 2-3 weeks, then taper, for severe cases or if aspirin is contraindicated.
• Implement long-term prevention with benzathine penicillin G every 3-4 weeks or daily oral penicillin V (250 mg twice daily) for at least 10 years or until the patient is 40 years of age, whichever is longer, as recommended by the 2021 ACC/AHA guideline 1.

Secondary Prevention

• The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement, as outlined in the 2009 scientific statement from the American Heart Association 1.
• For patients with documented valvular heart disease, the duration of rheumatic fever prophylaxis should be at least 10 years or until the patient is 40 years of age, whichever is longer, with lifelong prophylaxis recommended for high-risk patients, as stated in the 2021 ACC/AHA guideline 1.

Cardiac Involvement

• Manage heart failure with standard therapy (e.g., diuretics, ACE inhibitors) and consider surgical intervention for severe valvular disease, as recommended by the 2021 ACC/AHA guideline 1.
• Secondary rheumatic heart disease prophylaxis is required even after valve replacement, emphasizing the importance of long-term prevention and management, as highlighted in the 2021 ACC/AHA guideline 1.

From the FDA Drug Label

Following an acute attack, penicillin G benzathine (parenteral) may be given in doses of 1,200,000 units once a month or 600,000 units every 2 weeks. Prevention of Initial Attacks of Rheumatic Fever Penicillin is considered by the American Heart Association to be the drug of choice in the prevention of initial attacks of rheumatic fever (treatment of Streptococcus pyogenes infections of the upper respiratory tract e.g., tonsillitis, or pharyngitis). Prevention of Recurrent Attacks of Rheumatic Fever Penicillin or sulfonamides are considered by the American Heart Association to be the drugs of choice in the prevention of recurrent attacks of rheumatic fever

The management of Rheumatic Fever (Acute Rheumatic Fever) includes:

• Penicillin as the drug of choice for the prevention of initial attacks of rheumatic fever, by treating Streptococcus pyogenes infections of the upper respiratory tract.
• Penicillin G benzathine (parenteral) for prophylaxis, given in doses of 1,200,000 units once a month or 600,000 units every 2 weeks, following an acute attack.
• Erythromycin as an alternative for patients allergic to penicillin, for the treatment of penicillin-allergic patients, with a therapeutic dose administered for ten days.
• Penicillin or sulfonamides as the drugs of choice for the prevention of recurrent attacks of rheumatic fever, with oral erythromycin recommended for patients allergic to penicillin and sulfonamides 2 3

From the Research

Management of Rheumatic Fever (Acute Rheumatic Fever)

The management of acute rheumatic fever involves the use of anti-inflammatory agents to prevent or reduce further heart valve damage.

• The use of corticosteroids, such as prednisone, and intravenous immunoglobulins has been compared to aspirin and placebo in several studies 4, 5, 6, 7, 8.
• The results of these studies suggest that there is no significant difference in the risk of cardiac disease at one year between corticosteroid-treated and aspirin-treated groups 4, 7, 8.
• However, some studies suggest that corticosteroids may be beneficial in reducing the incidence of long-term valvular disease in patients with active carditis 5, 6.
• The treatment of rheumatic fever also involves the use of antibiotics, such as penicillin, to eradicate streptococci 6.
• Secondary prophylaxis, such as monthly intramuscular injections of benzathine penicillin, is also important in preventing recurrences of rheumatic fever 5, 6.

Treatment Options

• Aspirin: may be sufficient for cases with mild or no carditis 6.
• Corticosteroids: may be beneficial in reducing the incidence of long-term valvular disease in patients with active carditis 5, 6.
• Intravenous immunoglobulins: have been compared to aspirin and placebo in several studies, but the results are inconclusive 4, 7, 8.
• Penicillin: is used to eradicate streptococci and prevent recurrences of rheumatic fever 6.

Recommendations

• New randomized controlled trials are warranted to assess the effects of corticosteroids and other new anti-inflammatory agents in patients with acute rheumatic fever 4, 7, 8.
• Advances in echocardiography will allow for more objective and precise assessments of cardiac outcomes 4, 7, 8.