What is the management of chikungunya?

Management of Chikungunya

Chikungunya management is primarily supportive and symptomatic, focusing on pain control with acetaminophen while strictly avoiding NSAIDs and aspirin, adequate hydration, and rest during the acute phase.

Acute Phase Management (First 7-10 Days)

Pain and Fever Control

• Acetaminophen (paracetamol) is the exclusive first-line analgesic and antipyretic for chikungunya patients 1
• Avoid aspirin and NSAIDs entirely due to potential bleeding risk and platelet dysfunction, particularly since dengue co-infection cannot always be ruled out clinically 1
• Acetaminophen should be dosed at standard therapeutic levels based on patient weight 1

Hydration Management

• Ensure adequate oral hydration with oral rehydration solutions for patients with moderate dehydration 1
• Target fluid intake exceeding 2500ml daily to prevent dehydration from fever 1
• Patients should increase fluid intake as febrile illness is typically accompanied by mild dehydration 2

Supportive Measures

• Rest is essential during the acute febrile phase 3
• Tepid water sponging can be used for high fevers, particularly in children 2
• Monitor for severe manifestations including meningoencephalitis, fulminant hepatitis, and bleeding manifestations which may be life-threatening 3

Chronic Phase Management (Beyond 10 Days)

For Persistent Arthralgia

The evidence for chronic chikungunya management is limited and of very low quality, but available data suggests:

• Chloroquine may provide better chronic pain relief compared to placebo (RR 2.67,95% CI 1.23-5.77), though evidence quality is very low 4
• Disease-modifying anti-rheumatic drugs (DMARDs) showed reduction in pain (MD -14.80,95% CI -19.12 to -10.48) and disability (MD -0.74,95% CI -0.92 to -0.56) compared to hydroxychloroquine, but again with very low quality evidence 4
• Combination therapy with aceclofenac plus prednisolone showed reduced pain and better quality of life compared to aceclofenac monotherapy (p<0.001), though this comes from a single small trial 4

Important Caveats for Chronic Management

• All available evidence for chronic chikungunya treatment is of very low quality with high risk of bias 4
• Physicians should exercise extreme caution when prescribing interventions for chronic chikungunya, as insufficient evidence exists to draw firm conclusions about efficacy or safety 4
• Approximately 15% of patients develop chronic arthritis that may persist for months to years 3
• Chronic symptoms may include relapses with sensation of fever, asthenia, exacerbation of arthralgias, inflammatory polyarthritis, and stiffness 3

Diagnostic Confirmation

• PCR testing on serum during the first 5 days after symptom onset provides diagnostic confirmation 1
• IgM antibody testing against chikungunya from day 6 onwards can confirm diagnosis 1
• Viral culture remains the gold standard but is less practical clinically 3

Special Populations

Pregnant Women

• Acetaminophen remains the safest analgesic option for pregnant women with chikungunya 1
• Monitor for potential vertical transmission, as infected mothers may miscarry and newborns can be infected in utero with congenital illness 5

Children

• Acetaminophen dosing must be carefully calculated based on weight 1
• Tepid water sponging should be used frequently for high fevers 2

Elderly and Comorbid Patients

• Advanced age and various comorbidities are associated with severe or atypical forms of chikungunya fever 5
• These patients require closer monitoring for severe manifestations including neurological and cardiac complications 5

Critical Pitfalls to Avoid

• Never use NSAIDs or aspirin in suspected chikungunya due to bleeding risk and inability to exclude dengue co-infection 1
• Do not prescribe limited analgesics like dipyrone in sub-therapeutic doses, which is a common error 6
• Avoid prescribing unproven therapies for chronic symptoms without discussing the very low quality of available evidence with patients 4
• Do not dismiss chronic joint symptoms as psychosomatic—up to 50% of infected individuals develop chronic symptoms lasting months or years 6