Update on the treatment of musculoskeletal manifestations in chikungunya fever: a guideline

Abstract

Since the emergence of the chikungunya virus in Brazil in 2014, more than 700,000 cases have been reported throughout the country, corresponding to one-third of all cases reported in the Americas. In addition to its high attack rates, resulting in hundreds of thousands of cases, the disease has high chronicity rates with persistent joint manifestations for more than 3 months, which can spread to more than half of the patients affected in the acute phase. Pain associated with musculoskeletal manifestations, often disabling, has an effect on patients' quality of life at different stages of the disease. Currently, the challenge faced by specialists is identifying the best therapy to be instituted for symptom relief despite the limited number of published intervention studies. In 2016, a multidisciplinary group published pharmacological treatment protocols for pain in patients with chikungunya, which was incorporated into the guidelines for clinical management of the Brazilian Ministry of Health in 2017; in that same year, a consensus was published by the Brazilian Society of Rheumatology about diagnosis and treatment. After 5 years of experience with chikungunya epidemics, in 2019, specialists involved in the protocols of the Brazilian Society of Rheumatology and Brazilian Ministry of Health prepared an update with the main objective of developing flowcharts for the therapeutic approach of musculoskeletal manifestations in adult patients to enable specialists at different levels of healthcare to spread and apply this guideline in a systematic and simplified manner.

An evaluation of global Chikungunya clinical management guidelines – a systematic review

“…Half of the CMGs were in English (50%, 14/28); 9, 30–32, 34, 36, 37, 42, 44–47, 52, 54 43% (12/28) in Spanish 29, 35, 38– 41, 43, 48–50, 53, 55 and 7% (2/28) in Portuguese. 33, 51 Most were produced by National Health Organisations (61%, 17/28), and 46% (13/28) 32–34, 36, 37, 39, 44–46, 51–54 published in the last 5 years (Table 1).…”

“…Half of the CMGs were produced in Latin Americas (50%, 14/28), 29, 33, 35, 38, 40, 41, 43, 48–51, 53–55 14% in Europe (4/28), 9, 30, 31, 39 14% in Asia (4/28), 37, 42, 44, 45 11% in North America (3/28) 32, 34, 36 and 11% by global organisations (3/28) 32, 34, 52 (Figure 2). Most were produced by organisations in high- or upper-middle income countries (61%, 17/28), 33, 35, 38, 40, 41, 48, 49, 51, 54, 55 followed by lower-middle-income countries (18%, 5/28). 29, 37, 43–45 None were produced in a low-income country.…”

“…Most CMGs (89%, 25/28) 9, 29, 31–35, 37–42, 44–53, 55 mentioned vulnerable groups including children (75%, 21/28), 9, 29, 31, 32, 37–43, 45, 46, 48–51, 53, 55 pregnant women (68%, 19/28), 9, 29, 32, 33, 35, 38–45, 47–49, 51, 52, 53 people aged >65 years (96% 27/28), 9, 29, 31–55 people living with HIV (21%, 6/28) 29, 38, 40, 41, 49, 55 and people living with comorbidities (61%, 17/28). 9, 29, 31, 32, 34, 36–38, 40, 41, 43, 44, 48–51, 54 Many (61% (17/28) 30, 31, 33–37, 41, 42, 44, 45, 53–55 provided some guidance for all of these groups; however, recommendations varied in their level of detail with only a minority giving specific supportive care guidance for pregnant women and children.…”

“…Fifty-four percent of CMGs (15/28) 33, 35, 37, 38, 40–45, 47–49, 51, 52 recommended hospitalisation for severe cases; however, only a minority (39%, 11/28) 9, 29, 33, 34, 37, 38, 41, 46, 51, 52, 54 gave guidance regarding the clinical management of severe cases. The CMGs (54%, 15/28) 33, 35, 37, 38, 40–45, 47–49, 51, 52 providing guidance regarding hospitalisation criteria gave several indications including: any signs of haemodynamic instability (46%, 13/28), 33, 35, 38, 41–45, 47–49, 51, 52 or atypical chikungunya (36%, 10/28), 29, 33, 35, 38, 41, 43, 47–49, 52 severe pain unresponsive to analgesia (25%, 7/28), 35, 37, 38, 41, 42, 44, 45 signs of haemorrhage (46%, 13/28) 29, 33, 35, 38, 41–45, 47–49 and signs of decompensation from underlying comorbidities (25%, 7/28).…”

Classification of chikungunya cases: a proposal

“…Musculoskeletal manifestations are the most common, and their management is related to different phases 9 - 10 . Chronologically, the spectrum of the disease involves three phases (acute, postacute, and chronic).…”