What treatment is recommended for shingles pain at night that persists despite valacyclovir (valacyclovir) and Percocet (oxycodone and acetaminophen)?

From the Guidelines

For persistent shingles pain at night that continues despite valacyclovir and Percocet, adding a gabapentinoid such as gabapentin or pregabalin is recommended as the first-line treatment. This is based on the most recent and highest quality study available, which suggests that gabapentinoids have a clinically relevant effect on neuropathic pain conditions, including shingles pain 1.

The treatment approach can be tailored to the individual patient's needs, with the following options considered:

• Gabapentin, starting at 300mg at night, gradually increasing to 300-600mg three times daily as tolerated
• Pregabalin, starting at 75mg twice daily, increasing to 150-300mg twice daily if needed
• Topical treatments like lidocaine 5% patches applied to the painful area for 12 hours daily or capsaicin cream for localized relief
• Non-medication approaches, such as wearing loose cotton clothing over affected areas, using cool compresses, and maintaining good sleep hygiene

It's essential to note that tricyclic antidepressants, such as amitriptyline, can also be effective for neuropathic pain, but they may have more side effects and require careful titration 1. Corticosteroids, like prednisone, may be considered for severe cases, but their effectiveness is inconsistent, and toxicity is a concern, particularly with long-term use 1.

The chosen treatment should be based on the patient's individual needs, medical history, and potential interactions with other medications. Regular follow-up and reassessment of pain and health-related quality of life are crucial to adjust the treatment plan as needed 1.

From the Research

Treatment Options for Shingles Pain at Night

• Despite valacyclovir and Percocet, shingles pain at night can be challenging to manage.
• According to 2, tricyclic antidepressants or anticonvulsants, often given in low dosages, may help to control neuropathic pain.
• Additionally, capsaicin, lidocaine patches, and nerve blocks can also be used in selected patients 2.
• The study 3 suggests that amitriptyline and desipramine, despite their limited efficacy, are the reference treatments for postherpetic neuralgia.
• Gabapentin, although somewhat less effective, is a possible second-line option 3.

Alternative Therapies

• A case report 4 found that serial thoracic transforaminal epidural steroid injections (TFESIs) effectively treated post-herpetic neuralgia and achieved near-complete pain resolution.
• TFESI can be considered an early and first-choice treatment for post-herpetic neuralgia, but several courses may be required to achieve adequate and prolonged symptom control 4.

Management Guidelines

• The management of herpes zoster and post-herpetic neuralgia involves antivirals, topical or systemic agents, and other treatments 5.
• For patients with more severe pain, systemic agents such as gabapentin, pregabalin, amitriptyline, and opioid analgesics can be considered 5.
• Early initiation of gabapentin or amitriptyline after the onset of herpes zoster is suggested for patients at high risk of developing post-herpetic neuralgia 5.

Valacyclovir Treatment

• Valacyclovir 1.5 g twice daily has been shown to be safe and effective for the treatment of uncomplicated herpes zoster in immunocompetent patients over 18 years of age 6.
• Twice-daily dosing may help increase patient compliance and therefore increase the effectiveness of treatment of the acute herpes zoster rash and the prevention of zoster-associated pain 6.