From the Guidelines
The best approach for pain control in a 73-year-old female with herpes zoster involves a multimodal strategy starting with antiviral therapy plus analgesics, prioritizing the reduction of morbidity, mortality, and improvement of quality of life. Given the potential for postherpetic neuralgia (PHN) and other complications, especially in older adults 1, prompt initiation of antivirals such as valacyclovir, famciclovir, or acyclovir for 7 days is crucial to limit viral replication and reduce the severity and duration of acute pain.
For pain management, it is recommended to begin with scheduled acetaminophen (650-1000mg every 6 hours, not exceeding 3000mg daily in elderly patients) plus a topical agent like lidocaine 5% patch applied to the affected dermatome for 12 hours daily. If pain persists, adding a gabapentinoid such as gabapentin or pregabalin can be beneficial. The use of lower doses of centrally acting analgesics is advised to avoid confusion and deterioration of cognitive performance, which is particularly important in the elderly population 1.
Key considerations in managing pain in this patient include:
- Assessing pain using a standardized scale, such as the 0 to 10 scale 1
- Developing a pain management plan that considers the etiology, location, quality, quantity, duration, and intensity of pain, as well as factors that aggravate or relieve pain 1
- Controlling pain that interferes with therapy or daily activities
- Monitoring for and minimizing potential side effects of medications, especially in elderly patients.
Given the complexity of pain management in herpes zoster, particularly in older adults, a comprehensive and multimodal approach that addresses both the viral cause and the neuropathic nature of the pain, while carefully considering age-related concerns, is essential for optimizing outcomes and improving quality of life.
From the FDA Drug Label
Of the total number of subjects in clinical trials of VALTREX, 906 were 65 and over, and 352 were 75 and over. In a clinical trial of herpes zoster, the duration of pain after healing (post-herpetic neuralgia) was longer in subjects 65 and older compared with younger adults. The recommended dosage of VALTREX for treatment of herpes zoster is 1 gram 3 times daily for 7 days Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started within 48 hours of the onset of rash.
The best approach for pain control in a 73-year-old female with herpes zoster (shingles) is to use valacyclovir at a dose of 1 gram 3 times daily for 7 days. However, considering the patient's age, it is essential to assess her renal function before initiating treatment, as elderly patients are more likely to have reduced renal function and require dose reduction 2.
Additionally, pregabalin can be considered for the management of postherpetic neuralgia, which is a common complication of herpes zoster in elderly patients. The dosage of pregabalin should be adjusted based on renal function, and the patient should be monitored for adverse reactions 3.
Key points:
- Initiate valacyclovir at the earliest sign or symptom of herpes zoster
- Assess renal function before initiating treatment
- Consider pregabalin for the management of postherpetic neuralgia
- Monitor for adverse reactions, especially in elderly patients 2, 3
From the Research
Pain Control for Herpes Zoster in a 73-Year-Old Female
- The management of herpes zoster (shingles) in older adults, such as a 73-year-old female, involves antiviral therapy and pain control 4, 5.
- Antiviral medications like valacyclovir, acyclovir, and famciclovir are effective in reducing the severity and duration of herpes zoster, including zoster-associated pain (ZAP) and postherpetic neuralgia (PHN) 6, 7.
- Valacyclovir, in particular, has been shown to be safe and effective in immunocompetent patients over 18 years of age, with a twice-daily dosing regimen that may enhance patient compliance 6.
- For pain control, topical lidocaine or capsaicin, and oral gabapentin, pregabalin, or tricyclic antidepressants may be used to manage PHN, which is a common complication of herpes zoster 5.
- The varicella zoster virus vaccine is also recommended for adults 50 years and older to decrease the incidence of herpes zoster 5, 8.
Treatment Options
- Valacyclovir 1.5 g twice daily for 7 days has been shown to be effective in reducing ZAP and PHN 6.
- Acyclovir 800 mg five times daily for 7 days is also an option, although valacyclovir may have a faster onset of action 7.
- Famciclovir 500 mg three times daily for 7 days is another alternative, with similar efficacy to valacyclovir 7.