From the Guidelines
Shingles treatment in the elderly should begin with antiviral medications started within 72 hours of rash onset for maximum effectiveness, as recommended by the most recent guidelines. The recommended antivirals include valacyclovir (1,000 mg three times daily for 7 days), famciclovir (500 mg three times daily for 7 days), or acyclovir (800 mg five times daily for 7-10 days), with valacyclovir or famciclovir generally preferred due to less frequent dosing 1.
Key Considerations
- Pain management is crucial and may include acetaminophen, NSAIDs (used cautiously in the elderly), topical lidocaine patches, or gabapentin (starting at 300 mg daily and gradually increasing) 1.
- For severe cases, short-term oral corticosteroids like prednisone may be considered.
- Elderly patients should keep the rash clean and covered to prevent bacterial infection and transmission to others.
- Dose adjustments may be necessary for patients with kidney impairment, which is common in older adults.
- Early treatment is essential as it reduces the risk of postherpetic neuralgia, a painful complication that occurs more frequently in elderly patients.
Prevention
- The shingles vaccine (Shingrix) is recommended for prevention in those who have already had shingles to prevent recurrence, as the elderly immune system is less effective at suppressing the dormant varicella-zoster virus that causes shingles 1.
- Vaccination against shingles is particularly important for older patients who are at increased risk of herpes zoster, especially those taking medications that increase this risk, such as JAK inhibitors.
Treatment Approach
- The choice of antiviral medication should be based on the patient's renal function, tolerance, and potential interactions with other medications.
- Monitoring for potential side effects and adjusting the treatment plan as needed is crucial for optimal outcomes.
- A multidisciplinary approach, including pain management specialists and dermatologists, may be necessary for comprehensive care.
From the FDA Drug Label
Of 816 patients with herpes zoster in clinical studies who were treated with famciclovir, 248 (30. 4%) were greater than or equal to 65 years of age and 103 (13%) were greater than or equal to 75 years of age. No overall differences were observed in the incidence or types of adverse events between younger and older patients. In general, appropriate caution should be exercised in the administration and monitoring of famciclovir in elderly patients reflecting the greater frequency of decreased renal function and concomitant use of other drugs.
Shingles treatment in elderly with famciclovir:
- No overall differences in adverse events were observed between younger and older patients.
- Caution is recommended due to the potential for decreased renal function and concomitant use of other drugs in elderly patients.
- No dosage adjustment is recommended based on age unless renal function is impaired 2.
Of 376 subjects who received acyclovir in a clinical study of herpes zoster treatment in immunocompetent subjects ≥50 years of age, 244 were 65 and over while 111 were 75 and over. No overall differences in effectiveness for time to cessation of new lesion formation or time to healing were reported between geriatric subjects and younger adult subjects
Shingles treatment in elderly with acyclovir:
- No overall differences in effectiveness were observed between geriatric subjects and younger adult subjects.
- Elderly patients are more likely to have reduced renal function and require dose reduction 3.
From the Research
Shingles Treatment in the Elderly
- Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus (VZV) that causes chickenpox in children 4.
- Antiviral therapy is the primary treatment for herpes zoster, with acyclovir being the gold standard for many years 4.
- Newer antivirals such as famciclovir and valacyclovir offer less frequent dosing and are also effective in treating herpes zoster 4.
Postherpetic Neuralgia (PHN) Treatment
- PHN refers to pain lasting more than 2 months after an acute attack of herpes zoster 4.
- Treatment of established PHN includes pharmacologic and nonpharmacologic therapy 4.
- Therapeutic strategies to prevent PHN include the use of oral corticosteroids, nerve blocks, and treatment with standard antiviral therapy 4.