What is the treatment for chikungunya?

Treatment for Chikungunya

Chikungunya treatment is primarily supportive with adequate hydration and acetaminophen for pain relief, while strictly avoiding NSAIDs during the acute phase (first 7-10 days) due to bleeding risk from potential dengue co-infection. 1

Acute Phase Management (First 7-10 Days)

Hydration

• Provide adequate oral fluids as the cornerstone of treatment 1
• Ensure oral rehydration solutions are available for patients who can tolerate oral intake 1

Pain and Fever Control

• Use acetaminophen (paracetamol) exclusively for pain and fever relief during the acute phase 1, 2
• Absolutely avoid NSAIDs (ibuprofen, naproxen, aspirin) during the first 7-10 days because dengue co-infection cannot be reliably excluded, and NSAIDs increase bleeding risk 1, 2
• This is critical since both diseases share the same mosquito vector (Aedes species) and geographic distribution, making co-infection possible 3, 1

Monitoring Requirements

• Watch for neurological complications, particularly in high-risk groups 1
• Monitor for signs of severe disease requiring hospitalization 1

Chronic/Post-Acute Arthritis Management (After Acute Phase)

When Severe Joint Pain Persists Beyond Acute Phase

The evidence for chronic chikungunya arthritis treatment shows mixed results, but some approaches have demonstrated benefit:

• NSAIDs may be used after the acute phase (>7-10 days) once dengue is excluded, and can reduce pain for up to 24 weeks of treatment 4
• Methotrexate (20 mg/week) combined with low-dose dexamethasone (0-4 mg/day) showed significant improvement in a Brazilian cohort, with sustained benefit 5 months after treatment 5
• Hydroxychloroquine monotherapy demonstrated positive effects for post-chikungunya arthritis pain relief in one study 6
• Triple therapy with methotrexate plus sulfasalazine and hydroxychloroquine showed positive effects for reducing arthritis pain 6

However, systematic review evidence indicates that chloroquine, hydroxychloroquine as monotherapy, stand-alone methotrexate, and ribavirin show no clear added benefit compared to anti-inflammatory drugs or placebo 4. Chloroquine specifically showed negative effects for post-chikungunya arthralgia 6.

Non-Pharmacological Options for Chronic Symptoms

• Transcranial direct current stimulation, elastic band exercises, and Pilates method showed positive effects for pain relief and joint function improvement 6
• These approaches may be considered as adjunctive therapy 6

High-Risk Populations Requiring Close Monitoring

Elderly Patients (>60 Years)

• Higher risk for severe manifestations and neurological complications 3, 1
• Case fatality rate of approximately 10% among those with neurological involvement 3, 1

Infants and Neonates

• Require close monitoring as they are at higher risk for severe disease 1
• Maternal-fetal transmission near term can cause severe neonatal complications 3, 1
• Encephalitis from perinatal transmission has been reported 3

Pregnant Women

• Monitor closely for vertical transmission, particularly near term 1
• Acetaminophen remains the safest analgesic option 2

Critical Diagnostic Considerations

• PCR testing is most effective during days 1-4 of symptoms for direct viral detection 1
• IgM antibody testing should be used from day 5 onward 1
• Classic presentation includes fever, headache, myalgia, and severe polyarthralgia/arthritis 1
• Incubation period is typically 2-3 days (range: 1-12 days) 1

Common Pitfalls to Avoid

• Do not use NSAIDs during the acute phase - this is the most critical error that increases bleeding risk if dengue co-infection is present 1, 2
• Do not misdiagnose as dengue fever due to similar initial presentation and shared vector 1
• Do not fail to consider chikungunya in travelers returning from endemic areas (Africa, Asia, Indian Ocean, Americas, Pacific Islands) 3, 1
• Do not prescribe limited analgesics like dipyrone in sub-therapeutic doses 7

Rare but Serious Complications

• Encephalitis, encephalopathy, acute disseminated encephalomyelitis, and Guillain-Barré syndrome have been reported, though rare 3, 1
• Neurological presentations carry approximately 10% case fatality rate 3, 1
• Long-term neurocognitive outcomes may be poor in those with neurological involvement 3