Naproxen Therapy in Rheumatic Fever

Abstract

Source: Uziel Y, Hashkes PJ, Kassem E, et al. The use of naproxen in the treatment of children with rheumatic fever. J Pediatr. 2000;137:269–271.Nineteen patients (7 males) at the Sapir Medical Center, Israel, who had acute rheumatic fever (ARF) without carditis were treated with naproxen. Age range was 4–14 years (mean 9.1). Patients had fever and arthritis for a median of about 4 days (range 1–11) prior to administration of naproxen. Outcome measured was the number of days from start of treatment until resolution of fever and arthritis. Patients were observed for side effects and the development of carditis. All patients had prompt resolution of fever (median 1 day, range 1–2 days) and all but one had resolution of arthritis within a median of 1 day of beginning naproxen (range 1–30 days). The one outlier was a patient with small joint involvement whose arthritis persisted for 30 days. No GI, skin, hepatic or renal side effects were observed. No patients developed carditis over the next 6 months.Although ARF was a very common problem in large US inner-city communities in the first half of the 20th century, with attack rates of 50–60/100,000 children, by the early 1980s the incidence had declined to 0.2–0.8 cases/100,000.1 However, when a 1987 case report from Utah2 was followed by similar reports from multiple cities, it became clear that the disease was still endemic across the country. In contrast to the pattern of the early 20th century, children currently affected by ARF seem to be from suburban middle class families. Studies in the 1950s and 1960s recommended the use of the only anti-inflammatory medications available—salicylates and corticosteroids.3 The use of corticosteroids as a first line treatment has since become controversial.4 As there was no literature on the use of nonsteroidal anti-inflammatory drugs (NSAIDS) which were developed in the late 1970s and early 1980s, many clinicians felt that they still had to use aspirin for ARF, although by the early 1990s naproxen had replaced it for the treatment of JRA.5 Indeed, a 1997 review of ARF recommended salicylates as initial anti-inflammatory therapy.6 Although pediatric rheumatologists have been using naproxen to treat the arthritis of ARF for years and have found it as effective as salicylates and without those drugs’ adverse effects, until the appearance of this article only anecdotal reports had been published. Uziel et al have shown that naproxen seems to be as effective as aspirin, and that children so treated did not seem to develop carditis at an unusual rate. This case series, although small, is very helpful to the clinician who wants to avoid the use of aspirin (and all of its potential complications) in children with the arthritis of ARF.The dose of naproxen used in this study was 10–20 mg/kg per day divided twice daily which continued until the sedimentation rate normalized. We wonder why our pediatric rheumatologists have not yet collaborated on either a randomized controlled trial comparing naproxen to aspirin or a sufficiently large case series to establish with confidence that the efficacy and safety of NSAIDs in ARF are as good or better than the aspirin therapy used in the past. Such evidence is needed. A case series of 19 patients followed for 6 months seems a flimsy foundation for therapy of ARF.