Indication
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Drug options listed in order of preference
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Comment
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Eradication of inciting streptococcal infection
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1. Benzathine benzylpenicillin G 1,200,000 units (child
<20 kg: 600,000 units, ≥20 kg: 1,200,000 units) intramuscularly, single dose
OR
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Streptococcal infection may not be evident by the time acute rheumatic fever manifests (e.g. cultures often negative), but eradication therapy for possible persisting streptococci is recommended.
Intramuscular penicillin is preferred as streptococcal eradication therapy due to better adherence and its subsequent ongoing use in secondary prophylaxis.
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2. Phenoxymethylpenicillin 500 mg (child: 15 mg/kg up to
500 mg) orally, every 12 hours for 10 days
OR
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3. For patients with penicillin hypersensitivity (non-severe): cefalexin 1 g (child: 25 mg/kg up to 1 g) orally, every
12 hours for 10 days
OR
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Between 3% and 30% of group A streptococcus isolates internationally are resistant to macrolide antibiotics (e.g., azithromycin).
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4. For patients with immediate penicillin hypersensitivity: azithromycin 500 mg (child: 12 mg/kg up to 500 mg) orally, daily for 5 days
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Initial analgesia while awaiting diagnostic confirmation:
mild to moderate pain
severe pain
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Paracetamol 1000 mg (in children: 15 mg/kg) orally, every four hours as needed up to a maximum of 60 mg/kg/day or 4000 mg/day
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Initial analgesia is preferred during diagnostic uncertainty to avoid the masking effect that anti-inflammatory use can have on migratory joint symptoms, fever and concentrations of inflammatory markers.
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Tramadol immediate-release 50–100 mg (in children: 1–2 mg/kg) orally, every four hours as needed up to a maximum of 400 mg/day
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Tramadol (or codeine) is usually avoided in children
<12 years of age due to variable metabolism. Use only when strong analgesia is essential and cautious monitoring is available.
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Symptomatic management of arthritis/arthralgia after confirmation of acute rheumatic fever diagnosis
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1. Naproxen immediate-release 250–500 mg (in children: 10–20 mg/kg/day) orally twice daily, up to a maximum of 1250 mg daily
OR
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Naproxen may be safer than aspirin and convenient due to twice-daily dosing and the availability of oral suspension.
Ibuprofen is well tolerated and readily available, but there are less data and experience with its use for acute rheumatic fever than those associated with naproxen.
The dose of NSAIDs needed for acute rheumatic fever is generally higher than the dose recommended for other conditions; therefore, it may be appropriate to start at the higher dose range.
Due to the rare possibility of Reye’s syndrome in children, aspirin may need to be discontinued
during intercurrent acute viral illness; thus, influenza vaccination is strongly recommended to reduce the likelihood of this case.
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2. Ibuprofen 200–400 mg (in children: 5–10 mg/kg) orally three times daily, up to a maximum of 2400 mg daily
OR
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3. Aspirin 50–60 mg/kg/day orally, in 4–5 divided doses in adults and children. Dose can be escalated up to a maximum of 80–100 mg/kg/day in 4–5 divided doses
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Symptomatic management of moderate to severe chorea
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1. Carbamazepine 3.5–10 mg/kg per dose orally twice daily
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Treatment of Sydenham chorea should be considered if movements interfere substantially with normal activities.
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2. Sodium valproate 7.5–10 mg/kg per dose orally twice daily
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Symptomatic management of very severe chorea or chorea paralytica
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In addition to an anticonvulsant drug, consider adding a corticosteroid:
· Prednisolone 1–2 mg/kg up to a maximum of 80 mg orally once daily
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Symptomatic management of carditis
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Paediatric dosing:
· Furosemide (frusemide) 1–2 mg/kg orally as a single dose, then 0.5–1 mg/kg (to a maximum of 6 mg/kg) orally every 6–24 hours
· Spironolactone 1–3 mg/kg (initially) up to 100 mg orally in 1–3 divided doses daily. Round dose to a multiple of
6.25 mg (a quarter of a 25-mg tablet)
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Treatment of heart failure may be required for severe, acute carditis. Seek advice from a specialist cardiologist.
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· Enalapril 0.1 mg/kg orally in 1 or 2 divided doses daily, increased gradually over 2 weeks to a maximum of
1 mg/kg orally in 1 or 2 divided doses daily. Alternative ACE inhibitors: captopril, lisinopril
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The choice of ACE inhibitor will vary depending on the clinical situation. Seek advice from a specialist cardiologist.
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Adult dosing:
· Furosemide (frusemide) 20–40 mg orally or intravenously as a single dose followed by 20–40 mg orally or intravenously every 8–12 hours. Ongoing dose adjustment is based on clinical progression and renal function.
· Spironolactone may be added for patients with limited or no response to loop diuretic; 12.5–200 mg orally once daily with dose escalation based on clinical and electrolyte responses.
· Nitrate therapy may be added for patients with limited or no response to diuretic therapy and systolic blood pressure greater than 90 mmHg. Intravenous or topical glyceryl trinitrate may be used.
ACE inhibitor therapy with perindopril or ramipril is recommended in patients with moderate or severe left ventricular systolic dysfunction, unless contraindicated.
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The management of acute carditis follows the same principles as those for the management of acute heart failure. This table provides a guide to the initial management of acute heart failure due to acute carditis in adults. Seeking advice from a specialist cardiologist early is strongly recommended.
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Digoxin 15 micrograms/kg orally as a single dose, then
5 micrograms/kg after 6 hours, then 3–5 micrograms/kg (in adults: 125–250 micrograms) orally, daily
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Digoxin is rarely used for the treatment of acute carditis. Seek advice from a specialist cardiologist.
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Disease-modifying (immunomodulatory) treatments
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Prednisolone 1–2 mg/kg up to a maximum of 80 mg orally, once daily
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Considered for use in selected cases of severe carditis, despite meta-analyses in which the overall benefit was not evident.
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Secondary prophylaxis
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1. Benzathine benzylpenicillin G by deep intramuscular injection 1,200,000 units (≥20 kg) or 600,000 units (<20 kg) *
OR
2. Phenoxymethylpenicillin (penicillin V) 250 mg orally twice daily
OR
3. For patients with penicillin hypersensitivity (non-severe) or immediate penicillin hypersensitivity:
erythromycin 250 mg orally twice daily
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Every 28 days. †
Every 21 days for selected groups. ‡
Intramuscular penicillin is preferred due to greater effectiveness in head-to-head trial and better adherence.
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