How to treat a 45-year-old patient weighing 48 kg with Behcet's disease presenting with mouth ulcers and fever?

Treatment of Behçet's Disease with Mouth Ulcers and Fever

For a 45-year-old patient weighing 48 kg with Behçet's disease presenting with mouth ulcers and fever, topical corticosteroids should be used as first-line treatment for the oral ulcers, along with colchicine for systemic management of mucocutaneous manifestations.

Initial Management of Oral Ulcers

Topical Treatment

• Topical corticosteroid preparation 1:

  • Triamcinolone acetonide 0.1% ointment applied to oral ulcers 3-4 times daily 2
  • Apply after meals and before bedtime
  • Continue until resolution of ulcers (typically 7-10 days)

• Alternative topical options:

  • Lidocaine 2% gel for pain relief, applied as needed
  • Chlorhexidine 0.2% mouthwash twice daily to maintain oral hygiene 1

Systemic Treatment

First-line Therapy

• Colchicine 1:
  • Dosage: 0.5 mg twice daily (adjusted for patient's weight of 48 kg)
  • Particularly effective for mucocutaneous manifestations
  • Monitor for gastrointestinal side effects

Management of Fever

• For fever management:
  • Acetaminophen 500 mg every 6 hours as needed for fever
  • Evaluate for other systemic involvement if fever persists

Treatment Escalation Algorithm

For Resistant Oral Ulcers

If no improvement after 2-3 weeks of topical treatment and colchicine:

1. Add systemic corticosteroids 1:

   • Prednisone 20 mg daily (0.5 mg/kg/day) for 7-14 days with taper
   • Monitor for steroid-related side effects

2. If inadequate response to steroids:

   • Consider azathioprine 2-2.5 mg/kg/day (100-120 mg daily) 1
   • Requires baseline CBC, liver function tests, and TPMT testing

3. For highly resistant cases:

   • Consider TNF-alpha inhibitors such as infliximab 3
   • Reserved for cases resistant to conventional therapy

Special Considerations

Monitoring

• Reassess oral ulcers every 1-2 weeks during acute phase
• Monitor for signs of other organ involvement (eyes, skin, joints, vascular, neurological)
• Fever may indicate disease activity or infection - careful evaluation needed

Potential Pitfalls

• Avoid ciclosporine A if there are any neurological symptoms, as it may worsen neurological involvement 1, 4
• Do not rely solely on anticoagulants if vascular involvement is suspected, as the primary pathology is inflammation 1
• Be aware that colchicine alone may be insufficient for severe disease manifestations beyond mucocutaneous involvement 1

Complete Prescription for This Patient

1. Triamcinolone acetonide 0.1% ointment

   • Apply to oral ulcers 3-4 times daily after meals and before bedtime
   • Dispense: 1 tube (15g)
   • Refill: 1

2. Colchicine 0.5 mg tablets

   • Take 1 tablet twice daily with food
   • Dispense: 60 tablets
   • Refill: 2

3. Acetaminophen 500 mg tablets

   • Take 1-2 tablets every 6 hours as needed for fever or pain
   • Do not exceed 8 tablets in 24 hours
   • Dispense: 30 tablets
   • Refill: 1

4. Chlorhexidine 0.2% mouthwash

   • Rinse mouth twice daily for 30 seconds
   • Dispense: 1 bottle (300ml)
   • Refill: 1