From the Guidelines
The best management for herpes zoster (shingles) in a patient taking dostarlimab involves prompt antiviral therapy with valacyclovir 1000 mg three times daily, famciclovir 500 mg three times daily, or acyclovir 800 mg five times daily for 7-10 days, as recommended by the Infectious Diseases Society of America 1.
Key Considerations
- Treatment should begin as soon as possible after symptom onset, ideally within 72 hours, to reduce pain severity and duration.
- Pain management is also essential, using acetaminophen, NSAIDs, or in more severe cases, gabapentin (starting at 300 mg daily and titrating up) or pregabalin (starting at 75 mg twice daily).
- Dostarlimab therapy may need temporary interruption during severe shingles infection, but this decision should be made in consultation with the oncologist.
Patient Care
- Patients should keep the rash clean and covered to prevent transmission to others who are not immune to varicella.
- Close monitoring for complications is necessary as immunotherapy may affect immune response.
Prevention
- Shingles vaccination (Shingrix) should be considered before starting dostarlimab in eligible patients who haven't had it, though live vaccines (Zostavax) are contraindicated during immunotherapy. According to the guidelines, high-dose IV acyclovir remains the treatment of choice for VZV infections in compromised hosts, but oral acyclovir, famciclovir, and valacyclovir are beneficial for VZV infections in otherwise healthy hosts or as treatment to complete therapy once the patient has shown a clinical response to IV acyclovir 1.
From the Research
Management of Herpes Zoster in Patients Taking Dostarlimab
There are no direct research papers provided to assist in answering this question regarding the management of herpes zoster in a patient taking dostarlimab, an antibody targeting the programmed death-1 (PD-1) receptor. However, the provided studies discuss the management of herpes zoster using antiviral medications.
Antiviral Therapy for Herpes Zoster
- Valaciclovir has been shown to be effective in the management of herpes zoster, with studies indicating it is at least as effective as aciclovir in controlling symptoms and alleviating zoster-associated pain and postherpetic neuralgia 2, 3.
- Famciclovir has also been found to be effective in the treatment of herpes zoster, with similar efficacy to aciclovir and valaciclovir 3, 4.
- The dosage and duration of antiviral therapy may vary, with valaciclovir 1.5 g twice daily for 7 days being a safe and effective regimen for immunocompetent patients 5.
- Aciclovir, famciclovir, and valaciclovir have been compared in various studies, with no significant differences in efficacy found between them 2, 3, 4.
Corticosteroids in Herpes Zoster Treatment
- The use of corticosteroids in the treatment of herpes zoster is controversial, with some studies suggesting they may provide benefits in reducing pain and improving quality of life, but others finding no significant differences 3, 6.
- A randomized trial found that the addition of prednisolone to acyclovir therapy conferred only slight benefits over standard 7-day treatment with acyclovir, and did not reduce the frequency of postherpetic neuralgia 6.