What are the treatment options for herpes zoster (shingles) in the elderly?

From the Guidelines

Shingles treatment in the elderly should begin with antiviral medications started within 72 hours of rash onset for best effectiveness, as this approach has been shown to accelerate the rate of cutaneous healing and reduce the severity of acute pain in adults with herpes zoster (HZ) 1. The recommended antivirals include valacyclovir, famciclovir, or acyclovir, with valacyclovir or famciclovir generally preferred due to less frequent dosing.

• Key considerations for antiviral therapy:
  • Valacyclovir: 1,000 mg three times daily for 7 days
  • Famciclovir: 500 mg three times daily for 7 days
  • Acyclovir: 800 mg five times daily for 7-10 days Pain management is crucial and may include:
• Acetaminophen
• NSAIDs (used cautiously in the elderly)
• Topical lidocaine patches
• Gabapentin (starting at 300 mg daily and gradually increasing as needed) For severe pain, short-term opioids might be necessary. Additional measures to relieve symptoms and prevent complications include:
• Calamine lotion or colloidal oatmeal baths to relieve itching
• Keeping the rash clean and covered to prevent bacterial infection and transmission to others Prompt treatment is particularly important for older adults as they face higher risks of complications, including postherpetic neuralgia (persistent nerve pain) 1. The antiviral medications work by inhibiting viral DNA replication, reducing the severity and duration of the outbreak, while pain management addresses the inflammatory response and nerve damage caused by the reactivated varicella-zoster virus.

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 the elderly can be done with famciclovir.

• No overall differences were observed in the incidence or types of adverse events between younger and older patients.
• Caution should be exercised in the administration and monitoring of famciclovir in elderly patients due to the greater frequency of decreased renal function and concomitant use of other drugs 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

Acyclovir can also be used for shingles treatment in the elderly.

• No overall differences in effectiveness were reported between geriatric subjects and younger adult subjects.
• Elderly patients are more likely to have reduced renal function and require dose reduction, and are also more likely to have renal or CNS adverse events 3.

From the Research

Treatment Options for Shingles in the Elderly

• Antiviral medications such as acyclovir, valacyclovir, and famciclovir are commonly used to treat shingles in the elderly 4, 5, 6, 7, 8
• Valacyclovir has been shown to be more effective than acyclovir in accelerating the resolution of shingles-associated pain and postherpetic neuralgia 4, 5, 6, 8
• The recommended dosage of valacyclovir for the treatment of shingles is 1000 mg three times daily for 7 days 4, 5, 6
• Treatment with valacyclovir should ideally be started as soon as possible after symptoms appear, but it may still be effective when given later than 72 hours after rash onset 6
• In addition to antiviral medications, other treatments such as topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants may be used to control symptoms of postherpetic neuralgia 7

Prevention of Shingles in the Elderly

• The varicella zoster virus vaccine has been shown to decrease the incidence of shingles and is approved for adults 50 years and older 7
• The Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices recommends the vaccine for adults 60 years and older, except for certain immunosuppressed patients 7

Safety and Efficacy of Valacyclovir

• Valacyclovir has been shown to be well tolerated and safe in the treatment of shingles, with a similar adverse events profile to acyclovir and famciclovir 4, 5, 6, 8
• The most commonly reported adverse events with valacyclovir are nausea and headache 6