Management of Shingles in Multiple Myeloma Patients
Treat active shingles in multiple myeloma patients with acyclovir or valacyclovir immediately, and ensure all patients on proteasome inhibitor therapy receive antiviral prophylaxis to prevent herpes zoster reactivation. 1
Immediate Treatment of Active Shingles
When a multiple myeloma patient presents with active shingles (herpes zoster), initiate antiviral therapy promptly:
- Start acyclovir or valacyclovir immediately for treatment of active infection 2
- The standard treatment approach mirrors that for immunocompromised hosts, requiring early intervention to prevent complications including dissemination, visceral involvement, and post-herpetic neuralgia 3
- Multiple myeloma patients are at significantly higher risk (10-fold) for viral infections compared to healthy individuals, making aggressive treatment essential 1
Prophylactic Antiviral Therapy - Critical for Prevention
All multiple myeloma patients receiving proteasome inhibitor-based therapies (bortezomib, carfilzomib, ixazomib) must receive herpes zoster prophylaxis with acyclovir or valacyclovir - this is a Grade 1A recommendation 1
Specific Prophylaxis Guidelines:
- Continue antiviral prophylaxis for six weeks after discontinuation of the proteasome inhibitor, not just during active treatment 1
- Prophylaxis is also strongly recommended during autologous or allogeneic stem cell transplantation, particularly in patients with positive varicella-zoster serology 1
- For patients on immunomodulatory drugs (lenalidomide, pomalidomide), herpes virus prophylaxis should be administered to reduce viral reactivation risk 2
Treatment Regimen Selection Considerations:
The guidelines specifically note that herpes zoster prophylaxis is recommended for all patients treated with proteasome inhibitors 1, and this applies regardless of whether the patient is receiving:
- Bortezomib-based regimens (VRd, bortezomib/dexamethasone, bortezomib/liposomal doxorubicin) 1
- Carfilzomib-based regimens 1
- Ixazomib-based regimens 1
Risk Factors Requiring Heightened Vigilance
Multiple myeloma patients face compounded infection risk due to:
- Myeloma-related innate immunodeficiency affecting B-cells, dendritic cells, T-cells, and NK cells 1
- Age-related frailty - MM predominantly affects elderly patients with baseline immune senescence 1
- Treatment-induced immunosuppression from corticosteroids, proteasome inhibitors, and immunomodulatory agents 1
- Infections represent the main cause of death in myeloma patients, with 22% of deaths at one year attributed to infection 1
Monitoring and Complications
Watch for Severe Complications:
In immunocompromised myeloma patients, shingles can present with:
- More severe disease lasting up to two weeks with numerous lesions, often with hemorrhagic base 3
- High risk for cutaneous dissemination and visceral involvement including viral pneumonia, encephalitis, and hepatitis 3
- Involvement of two or more dermatomes is more common than in immunocompetent hosts 3
- Chronic or recurrent shingles may occur, particularly in heavily treated patients 3
Post-Herpetic Neuralgia Management:
- May persist for weeks to over one year 3
- Requires analgesics, potentially including amitriptyline hydrochloride and fluphenazine hydrochloride for severe cases 3
Critical Pitfall to Avoid
Never use live-attenuated varicella-zoster vaccine in multiple myeloma patients receiving active therapy - live vaccines are contraindicated (Grade 2C) due to risk of precipitating serious infections 1, 2
Additional Supportive Measures
- Maintain low threshold for empiric antibiotics if fever develops (temperature >38°C) given the immunocompromised state 2
- Ensure close household contacts receive all seasonal vaccines including influenza to create a protective environment 2
- Consider consultation with infectious disease specialists for complex cases or atypical presentations 2
The evidence strongly supports that prophylaxis is more effective than treatment in this vulnerable population, making routine antiviral prophylaxis during proteasome inhibitor therapy a cornerstone of supportive care in multiple myeloma management 1.