From the Guidelines
Shingles treatment in elderly patients should begin with antiviral medications started within 72 hours of rash onset for optimal effectiveness, with valacyclovir, famciclovir, or acyclovir as primary options, and vaccination with Shingrix is recommended for prevention, even after a shingles episode, to reduce recurrence risk. The primary goal of treatment is to reduce the severity and duration of symptoms, as well as the risk of postherpetic neuralgia, which affects up to 50% of untreated patients over 60 1.
Treatment Options
- 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) are the primary options, with valacyclovir and famciclovir generally preferred due to less frequent dosing.
Pain Management
Pain management is crucial and may include:
- Acetaminophen
- NSAIDs (used cautiously in the elderly)
- Gabapentin (starting at 100-300 mg at bedtime and gradually increasing)
- Pregabalin
- Lidocaine patches for localized pain For severe pain, short-term opioids may be necessary.
Prevention
Vaccination with Shingrix is recommended for prevention, even after a shingles episode, to reduce recurrence risk, as it has been shown to be safe and more efficacious compared with live-attenuated vaccine in elderly adults 1.
Patient Care
Elderly patients should keep the rash clean and avoid scratching to prevent secondary infection. Loose-fitting clothing and cool compresses can provide comfort. Patients should be monitored for postherpetic neuralgia, which occurs more frequently in older adults and may require continued pain management. Early treatment is essential as antivirals reduce viral replication, decrease the duration and severity of symptoms, and lower the risk of postherpetic neuralgia 1.
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 patients with famciclovir is approved, and no overall differences were observed in the incidence or types of adverse events between younger and older patients. However, caution should be exercised due to the greater frequency of decreased renal function and concomitant use of other drugs in elderly patients 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 patients with acyclovir showed no overall differences in effectiveness between geriatric subjects and younger adult subjects, but elderly patients are more likely to have reduced renal function and require dose reduction 3.
From the Research
Shingles Treatment in Elderly Patients
- Shingles, also known as herpes zoster, is a painful rash caused by the reactivation of the varicella-zoster virus 4.
- Elderly patients are more likely to develop shingles and experience complications such as postherpetic neuralgia (PHN) 4.
- Treatment for shingles in elderly patients typically involves antiviral medications such as acyclovir, valacyclovir, or famciclovir, which can help reduce the severity and duration of symptoms 5, 6, 7.
Antiviral Treatment Options
- Valacyclovir has been shown to be effective in reducing PHN-associated pain in elderly patients 5.
- A study comparing different dosages of valaciclovir found that high-dose valaciclovir (900 mg, three times daily) was more effective than low-dose valaciclovir (300 mg, twice daily) in reducing pain and preventing PHN in middle-aged and elderly patients 6.
- Valacyclovir has also been shown to be safe and effective in the treatment of herpes zoster, with a faster healing time and reduced incidence of PHN compared to acyclovir 7.
Prevention and Management
- The varicella zoster virus vaccine is recommended for adults 60 years and older to prevent shingles and reduce the risk of PHN 4.
- Treatment for PHN typically involves symptom control with topical lidocaine or capsaicin and oral gabapentin, pregabalin, or tricyclic antidepressants 4.
- Early treatment with antiviral medications such as valacyclovir can help reduce the severity and duration of shingles symptoms and prevent PHN in elderly patients 6, 7.