Pediatric Rheumatic Heart Disease Medication

Updated: Dec 01, 2019
  • Author: Thomas K Chin, MD; Chief Editor: Syamasundar Rao Patnana, MD  more...
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Medication

Medication Summary

The discussion of treatment and prevention of group A streptococci (GAS) pharyngitis outlined here are based on the recommendations of the 2010American Heart Association practice guidelines on prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. [58]

Medical therapy is directed at eliminating the group A streptococcal pharyngitis (if still present), suppressing inflammation from the autoimmune response, and providing supportive treatment for congestive heart failure. Attempts are ongoing to produce vaccines against GAS infection, but these have been limited due to the numerous strains of Streptococcus pyogenes as well as difficulty with cross-reactivity of bacterial proteins with host tissue. [59]

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Antibiotics

Class Summary

Antibiotics are used for the initial treatment of group A streptococcal pharyngitis to prevent the first attack of rheumatic fever (primary prophylaxis), for recurrent streptococcal pharyngitis, and for continuous therapy to prevent recurrent rheumatic fever and rheumatic heart disease (secondary prophylaxis).

Penicillin VK (Beepen-VK, Betapen-VK, Pen-Vee K)

For primary prophylaxis (to decrease likelihood of rheumatic fever by treating GABHS pharyngitis) as well as secondary prophylaxis (to prevent recurrent rheumatic fever/carditis) prophylaxis of rheumatic fever. Although amoxicillin may be used instead, there is no microbiologic advantage. 

Do not use tetracyclines to treat GABHS pharyngitis. For recurrent GABHS pharyngitis, a 10-day course of the same antibiotic may be repeated. Alternate drugs for penicillin-allergic patients include azithromycin, clarithromycin, or clindamycin.

Penicillin G benzathine/penicillin G procaine (Bicillin L-A, Wycillin)

For primary prophylaxis (to decrease likelihood of rheumatic fever by treating GABHS pharyngitis) as well as secondary prophylaxis (to prevent recurrent rheumatic fever/carditis) of rheumatic fever. Used when PO administration of penicillin is not feasible or dependable. IM therapy with penicillin is painful, but the discomfort may be minimized if penicillin G is brought to room temperature before the injection or a combination of benzathine penicillin G and procain penicillin G is used.

The initial course of antibiotics administered to eradicate streptococcal infection also serves as the first course of prophylaxis. An injection of IM benzathine penicillin G every 4 weeks is recommended as a regimen for secondary prevention for most patients in the United States. Administer the same dosage every 3 weeks in areas where rheumatic fever is endemic, in patients with residual carditis, and in high-risk patients.

Amoxicillin (Amoxil, Moxatag (DSC), Trimox)

Amoxicillin may be used instead of penicillin VK for primary prevention of rheumatic fever.

Clarithromycin

Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.

Azithromycin (Zithromax, Zmax)

Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.

Clindamycin (Cleocin, Cleocin Pediatric, ClindaMax Vaginal)

Alternate antibiotic for primary prevention of acute rheumatic fever in patients allergic to penicillin.

Sulfadiazine

Sulfadiazine may be used for secondary prevention of rheumatic fever.

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Anti-inflammatory Agents

Class Summary

The manifestations of acute rheumatic fever (including carditis) typically respond rapidly to therapy with anti-inflammatory agents. Aspirin, in anti-inflammatory doses, is the drug of choice. Prednisone is added when evidence of worsening carditis and heart failure is noted.

Aspirin (Anacin, Ascriptin, Bayer Aspirin)

Aspirin, also called acetylsalicylic acid, inhibits prostaglandin synthesis, which prevents formation of platelet-aggregating thromboxane A2. Begin administration immediately after the diagnosis of rheumatic fever is made. Initiation of therapy may mask manifestations of disease.

Prednisone (Deltasone, Orasone)

Predinisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear leukocyte (PMN) activity. If moderate to severe carditis is indicated by cardiomegaly, congestive heart failure, or third-degree heart block, 2 mg/kg/d PO should be used in addition to, or in lieu of, salicylate therapy. Prednisone should be continued for 2-4 weeks, depending on the severity of the carditis, and tapered during the last week of therapy. Adverse effects can be minimized by discontinuing prednisone therapy after 2 weeks and adding or maintaining salicylates for an additional 2-4 weeks.

Naproxen (Aleve, Anaprox, Anaprox DS)

Naproxen is an NSAID which is dosed at 10-20 mg/kg/day (maximum: 100 mg/day) in divided doses every 12 hours in children older than 2 years or at 250-500 mg twice daily (maximum: 1250 mg/day) in adults. Naproxen can cause gastrointestinal problems, and this side effect should be monitored.

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Therapy for Congestive Heart Failure

Class Summary

Heart failure in rheumatic heart disease is related in part to severe insufficiency of the mitral and aortic valves, and in part to pancarditis. Therapy traditionally has consisted of an inotropic agent (digitalis) in combination with diuretics (furosemide, spironolactone) and afterload reduction (captopril, enalapril).

Digoxin (Lanoxin)

Digoxin is an inotropic agent that was widely used in the past. Currently, its efficacy in congestive heart failure is under review. The potential for toxicity is present. Therapeutic levels and clinical effects are observed more quickly if loading doses of digitalis are administered before routine maintenance doses. Digoxin acts directly on cardiac muscle, increasing myocardial systolic contractions. Indirect actions result in increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure. Therapeutic digoxin levels are present at trough levels of 1.5-2 ng/mL.

Furosemide (Lasix)

Diuretics are frequently used in conjunction with inotropic agents for patients with congestive heart failure. When used aggressively, furosemide may result in hypokalemia and hypovolemia. There is a risk of hearing loss in premature infants. Furosemide increases excretion of water by interfering with the chloride-binding cotransport system, which in turn inhibits sodium and chloride reabsorption in the ascending loop of Henle and distal renal tubule.

Spironolactone (Aldactone, CaroSpir)

Spironolactone is used in conjunction with furosemide as a potassium-sparing diuretic. It competes with aldosterone for receptor sites in the distal renal tubules, increasing water excretion while retaining potassium and hydrogen ions.

Captopril (Capoten)

Captopril prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in lower aldosterone secretion. It is rapidly absorbed, but the bioavailability is significantly reduced with food intake. Captopril achieves a peak concentration in 1 hour and has a short half-life. The drug is cleared by the kidneys. Impaired renal function requires dosage reduction. It is absorbed well PO. Administer at least 1 hour before meals. If added to water, use within 15 minutes.

Captopril can be started at a low dose and titrated upward as needed and as the patient tolerates.

Systemic afterload reduction may be helpful in improving cardiac output, particularly in the setting of mitral and aortic valve insufficiency. Some patients have an unusually large hypotensive response. Use a small starting dose, particularly in patients with hypovolemia.

Enalapril (Vasotec)

Enalapril is indicated for chronic aortic and/or mitral regurgitation. It prevents conversion of angiotensin I to angiotensin II, a potent vasoconstrictor, resulting in increased plasma renin levels and a reduction in aldosterone secretion. Enalapril helps control blood pressure and proteinuria. It decreases the pulmonary-to-systemic flow ratio in the catheterization laboratory and increases systemic blood flow in patients with relatively low pulmonary vascular resistance.

Enalapril has a favorable clinical effect when administered over a long period. It helps prevent potassium loss in the distal tubules. The body conserves potassium; thus, less oral potassium supplementation is needed. The goal is to decrease afterload to the left ventricle (by reducing systemic blood pressure and by peripheral vasodilatation).

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