Rheumatic Fever in Emergency Medicine Medication
- Author: Steven J Parrillo, DO, FACOEP, FACEP; Chief Editor: Robert E O'Connor, MD, MPH more...
Medication Summary
Medical therapy for acute rheumatic fever involves the following areas:
- Treat group A streptococcal infection regardless of organism detection.
- Steroids and salicylates are useful in the control of pain and inflammation.
- Heart failure may require digitalis, fluid and sodium restriction, diuretics, and oxygen.
- Administer prophylaxis against GABHS infections to patients who have developed ARF. Most authorities suggest that prophylaxis be given for 5 years. For those who have rheumatic carditis, some authorities suggest lifelong prophylaxis.
- Phenobarbital and haloperidol may be helpful in controlling chorea.
- Note that clinical trials for a 6-valent and a 26-valent vaccine are likely to take place in the near future. Phase I trials have been very promising.
Antimicrobials
Class Summary
Because of the direct link between ARF and group A beta-streptococcal infection, the first step in treatment is the eradication of the organism.
Antibiotic regimens used for prevention of recurrence are mentioned briefly under Further Outpatient Care.
Penicillin G benzathine (Bicillin LA, Bicillin C-R)
Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible bacteria.
Because of its prolonged blood level, several authors believe this to be the DOC. Others prefer daily injections.
Penicillin G procaine (Crysticillin, Wycillin)
Long-acting parenteral penicillin (IM only) indicated in the treatment of moderately severe infections caused by penicillin G–sensitive microorganisms.
Some prefer 10-d therapy.
Administer by deep IM injection only into the upper outer quadrant of the buttock. In infants and small children, the midlateral aspect of the thigh may be the best site for administration.
Penicillin VK (Beepen-VK, Betapen-VK, Robicillin VK, Veetids)
Amoxicillin
Inhibits the biosynthesis of the cell-wall mucopeptide and is effective during the stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects. Penicillin VK is the oral alternative for the treatment of rheumatic fever.
Some authors suggest that once-daily amoxicillin is as effective and can be recommended as an alternative because compliance is likely to be better.
Erythromycin (EES, E-Mycin, Ery-Tab, Erythrocin)
DOC for patients allergic to penicillin; inhibits RNA-dependent protein synthesis, possibly by stimulating the dissociation of peptidyl tRNA from ribosomes, which inhibits bacterial growth.
In children, age, weight, and severity of infection determine the proper dosage. When bid dosing is desired, one-half the daily dose may be administered q12h. For more severe infections, the dose may be doubled.
Azithromycin (Zithromax)
Alternate antibiotic for treating GAS pharyngitis in patients allergic to penicillin.
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Glucocorticoids
Class Summary
These agents possess anti-inflammatory (ie, glucocorticoid) and salt-retaining (ie, mineralocorticoid) properties. Glucocorticoids cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli.
Prednisone (Deltasone, Sterapred)
Patients with carditis require prednisone instead of aspirin. The goal is to decrease myocardial inflammation. Some authors suggest that carditis without associated cardiomegaly or congestive heart failure be treated with aspirin instead of glucocorticoids.
Glucocorticoids are useful in treatment of inflammatory and autoimmune disorders. Reversing increased capillary permeability and suppressing PMN activity may decrease inflammation.
Neuroleptic agents
Class Summary
These agents may help to control the chorea associated with ARF.
Haloperidol (Haldol)
A dopamine receptor blocker useful in the treatment of irregular spasmodic movements of limbs or facial muscles.
Inotropic agents
Class Summary
Some believe that digoxin may be helpful in congestive heart failure.
Digoxin (Lanoxin)
Cardiac glycoside with direct inotropic effects and indirect effects on the cardiovascular system.
Effects on the myocardium involve a direct action on cardiac muscle that increases myocardial systolic contractions and indirect actions that result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure.
Anti-inflammatory agents
Class Summary
Reduce the inflammation associated with the disease process. Joints and heart are the targets of inflammation, but carditis is treated with glucocorticoids as noted above.
Aspirin (Ascriptin, Bayer Buffered Aspirin, Ecotrin)
Treats mild to moderate pain. Inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2.
Naproxen (Anaprox, Naprelan, Naprosyn)
For relief of mild to moderate pain; inhibits inflammatory reactions and pain by decreasing activity of cyclooxygenase, which is responsible for prostaglandin synthesis.
NSAIDs decrease intraglomerular pressure and decrease proteinuria.
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