From the Guidelines
Acute Rheumatic Fever (ARF) treatment should prioritize managing acute symptoms and preventing recurrences with antibiotics, anti-inflammatory medications, and long-term prophylaxis, as outlined in the most recent guidelines. The symptoms of ARF include joint pain, fever, and carditis, which can be managed with anti-inflammatory medications like aspirin (80-100 mg/kg/day divided into 4 doses for children) or naproxen, and corticosteroids like prednisone (1-2 mg/kg/day) for severe cases with carditis 1.
Acute Management
- Anti-inflammatory medications: aspirin or naproxen to reduce inflammation, particularly for joint pain and fever
- Corticosteroids: prednisone for severe cases with carditis
- Bed rest: recommended for patients with carditis until inflammation subsides
- Antibiotics: penicillin G benzathine as a single intramuscular injection (1.2 million units for adults, 600,000 units for children <27 kg) or oral penicillin V (250 mg twice daily for children, 500 mg twice daily for adults) for 10 days to eliminate any remaining streptococcal infection 1
Long-term Prophylaxis
- Monthly penicillin G benzathine injections or daily oral penicillin to prevent recurrence
- Duration of prophylaxis:
- For mild RHD—minimum of 10 years after most recent ARF, or until 21 years of age (whichever is longer); if no ARF, minimum of 5 years following diagnosis or until 21 years of age (whichever is longer) 1
- For moderate RHD—minimum of 10 years after most recent ARF, or until 35 years (whichever is longer); if no ARF, minimum of 5 years following diagnosis or until 35 years of age (whichever is longer) 1
- For severe RHD—minimum of 10 years after most recent ARF, or until 40 years of age (whichever is longer); if no ARF, minimum of 5 years following diagnosis or until 40 years of age (whichever is longer) 1
- Secondary prophylaxis should continue after valve surgery 1
Prevention of Recurrences
- Long-term antimicrobial prophylaxis is essential to prevent recurrences of ARF, particularly in patients with rheumatic heart disease (RHD) 1
- Prevention of RHD should aim at preventing the first attack of acute rheumatic fever (Abx tx of group A streptococcus) 1
From the FDA Drug Label
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 In patients who are allergic to penicillin and sulfonamides, oral erythromycin is recommended by the American Heart Association in the long-term prophylaxis of streptococcal pharyngitis (for the prevention of recurrent attacks of rheumatic fever).
The symptoms of Acute Rheumatic Fever (ARF) are not directly mentioned in the drug label. Treatment options for ARF include:
- Penicillin for the prevention of initial and recurrent attacks
- Sulfonamides for the prevention of recurrent attacks
- Oral erythromycin for patients allergic to penicillin and sulfonamides, for the long-term prophylaxis of streptococcal pharyngitis to prevent recurrent attacks of rheumatic fever 2
From the Research
Symptoms of Acute Rheumatic Fever (ARF)
- Intermittent fevers, fatigue, migratory joint pain, and weight loss following group A Streptococcus pharyngitis 3
- Clinical presentation can mimic other conditions, making diagnosis challenging 3
- Rheumatic carditis is a manifestation of ARF that may lead to rheumatic heart disease (RHD) 4
- ARF can cause inflammation in the heart, joints, CNS, and subcutaneous tissue 5
Treatment Options for ARF
- Penicillin G benzathine is used to treat ARF, and secondary prophylaxis with penicillin G benzathine can prevent recurrence of ARF 3, 6, 4
- Glucocorticoids may be used for severe carditis 3
- Aspirin or corticosteroids can be used to treat symptoms, but corticosteroids may be more effective in reducing inflammation 6
- Treatment of the acute episode controls symptoms and may limit cardiac damage 5
Secondary Prophylaxis
- Monthly intramuscular injections of benzathine penicillin are effective in preventing recurrence of ARF, but may not provide adequate coverage for the entire month 6
- Oral penicillin prophylaxis can be an alternative to benzathine penicillin, with similar recurrence rates 6
- Secondary prophylaxis is key to RHD control and can decrease the incidence of RHD 4