Chikungunya Treatment Regimen

Acute Phase (First 7-14 Days)

• Acetaminophen (paracetamol) - First-line agent for fever and joint pain
• Avoid NSAIDs during acute phase per WHO 2025 global arboviral guidelines due to hemorrhagic complications risk, particularly if dengue co-infection cannot be excluded
• Where dengue has been definitively ruled out, some regional guidelines allow NSAIDs for severe arthralgia

• Rest as tolerated (avoid immobility, which worsens stiffness; avoid strenuous activity)
• Fluids and hydration
• Physiotherapy to maintain joint function

• Corticosteroids during viremic phase - immunosuppression may impair viral clearance and mask co-infections
• Antivirals - no current agents show clinical benefit

Post-Acute Phase (2-12 Weeks)

• NSAIDs become appropriate for ongoing joint pain
• Short-term low-dose corticosteroids may be considered for severe joint involvement unresponsive to NSAIDs
• Continue physiotherapy and graded physical activity (aerobic and resistance exercise, hand therapy exercises)

Chronic Chikungunya Arthritis (>3 Months)

• Methotrexate 20 mg/week - Recommended across most guidelines as core first-line therapy
  • 2023 Brazilian cohort study (133 patients): Combined MTX/leflunomide with dexamethasone showed significant DAS28 and pain reduction at 4 weeks, with sustained response at 5 months
  • MTX achieves partial recovery in 75% of cases; better response in seropositive patients
  • Often combined with hydroxychloroquine for synergistic efficacy

• Hydroxychloroquine - For less severe chronic disease when MTX is contraindicated or not tolerated
• Listed as core treatment in multiple guidelines; safe, cost-effective, and accessible

• Methotrexate + Dexamethasone - 2024 RCT showed combination therapy improved outcomes in chronic chikungunya arthritis
• Leflunomide 20 mg/day - May be combined with MTX in resistant cases

• Anti-TNF agents (etanercept, adalimumab) - Reduce symptom chronicity and joint damage; safe even during CHIKV infection
  • Note: Anti-TNF therapy does not increase CHIKV infection risk but may delay viral clearance
• Rituximab - Second-line for inadequate response to conventional DMARDs

Adjunctive Measures

• Corticosteroids - Low-dose, short-term use in post-acute phase for severe inflammation
• Physiotherapy & Exercise - Essential component alongside pharmacotherapy
  • Improves muscle strength, reduces pain, maintains functional capacity
  • Particularly important for hand/wrist involvement
  • Heat therapy may help reduce pain and improve mobility
• Curcumin (natural product) - Emerging evidence for pain relief and symptom improvement in acute/chronic arthritis

Long-Term Follow-Up

• Rheumatology referral - Essential for arthritis persisting >3 months
• Monitor for secondary complications: rheumatoid arthritis (13.7% incidence post-CHIKV), cardiac involvement (myopericarditis), uveitis/retinitis, neurological sequelae

Vaccination (Prevention)

• Vimkunya (virus-like particle vaccine) - FDA-approved February 2025 for ages ≥12 years; single 0.8 mL IM dose
• IXCHIQ (live-attenuated) - Available in some countries; FDA license suspended in the US (August 2025)