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9/16/2013
1
Shingles: Using Interventional
Treatment Therapies to Treat Post-
Herpetic Neuralgia Julie W. Anderson, PhD, RN
Heidi J. Shannon, MS, FNP-BC
Disclosures
• Disclosures regarding non-FDA approved uses
of medications...
– Unlabeled/investigational uses of the following
products/devices will be disclosed to this audience:
pregabalin, gabapentin, duloxetine, and intrathecal
administration of methylprednisone
Clinical Overview
• Reactivation of virus
– Varicella zoster
– Dormant in dorsal
Root ganglia
• Susceptibility
– Varicella
– Varicella vaccine
• Reoccurrence
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Herpes Zoster/Shingles
• Disease occurrence
– 4/1,000 US citizens
• Incidence if >60
– 10/1,000
• Repeat episodes
• Hospitalizations
• Death rate
• Trends
Herpes Zoster/Shingles
• Presentation
– Flu-like symptoms: headache, photophobia,
malaise
– Itching, burning, painful, tingling of the skin
– Neurocutaneous rash: linear, torso, vesicles
(blister) appearance
Epidemiology
• Previous infection with VZV
• 1 million cases of HZ annually in the U.S.
• Risk – lifetime risk 30%
– Increasing age
– Immunosuppressive medical conditions
• Cancer, especially leukemia and lymphoma
• Human immunodeficiency virus
• Bone marrow or solid organ transplantation
– Certain medications
• Steroids, chemotherapy, transplant-related immunosuppressive medications
– Stress: hospitalization, surgery, etc.
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Initial Management
• No cure - art of treatment with science
assistance
• Treatment to manage symptoms, shorten
duration, and prevent long-term complications.
Options include:
– Antiviral medications
– OTC medications
– Topical antibiotics
– Corticosteroids?
Conventional Treatments
• Patient Education
– Oozing is contagious (esp. avoid pregnant women & immunocompromised patients)
– Don’t scratch, keep clean & dry
– Signs of bacterial infection, if present oral antibiotics
– Potential for post-herpetic neuralgia (PHN) - months to years in duration
– Vaccination: zostavax approved for 50+; insurance coverage 60+; one time vaccination
Complications of Shingles
• 1 in every 4 persons who get shingles will
experience a complication
– Bacterial infection
– Permanent scarring
– Vision impairment
– Ramsay Hunt syndrome
– Long-term pain: postherpetic neuralgia (PHN)
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Postherpetic Neuralgia (PHN)
• 10-18% of persons with HZ develop PHN
• Disabling pain syndrome
– Months or years in duration
– No consistently effective treatments
• 68% of HZ cases and 85% of PHN cases occur
in persons > 50 years
• Associated with impaired emotional well-
being, poor sleep, appetite, ↓social function,
and difficulty with ADL
Postherpetic Neuralgia (PHN)
• No consensus on what duration of pain
constitutes PHN (30 vs. 90 days)
• Symptoms:
– Pain
– Sensitivity to light touch
– Itching and numbness
– Weakness or paralysis
• Unsatisfactory pain control is common
Differential Diagnoses
• Pain
– DDX: PE, pleuritic & anginal chest pain, herpes simplex, acute MI, pericarditis, renal colic, prolapsed intervertebral disc
– Descriptors: allodynia, throbbing, burning, stabbing
• Rash
– DDX: acute herpes simplex, contact dermatitis, acute impetigo, folliculitis, acute scabies, insect bites, drug-induced rash, & acute varicella
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HZ Treatment Strategy
HZ Treatment Strategy
Conventional Treatments
• Cornerstone includes anti-viral medications when 1
of the following criterion is met: • <72 hours from symptom onset;
• Age >50;
• > moderate pain rating; or
• Non-truncal involvement of rash.
• Acyclovir 800mg 5x/day for 7-10d; OR famciclovir
500mg 3x/d x7d; OR valacyclovir 1000mg 3x/d x 7d
• Acetaminophen and/or tramadol
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HZ Treatment Strategy
Conventional Treatments
• Corticosteroid taper- controversy
• Thermal & mechanical allodynia
– Lidocaine patch
• 2 week trial
• No systemic involvement
• MOA: hypothesis Na+ channel blockade thus disrupting
peripheral pain impulse blockade at site
– Capsaisin Cream
• Initial burning sensation-intolerable to some patients
• MOA: desensitization sensory fibers for noxious sensations
HZ Treatment Strategy
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Conventional Treatments
• Non-opioid pain control options
– Tricyclic antidepressants
(nortiptyline/amitriptyline)
• MOA: unclear, possibly ↑endogenous opioids via delta
receptors
• High occurrence of side effects
– Duloxetine- not FDA approved specifically for
PHN but other neuropathic pain approval
• MOA-SNRI: works on pain pathway, reduces
hyperalgesia/allodynia
Conventional Treatments
Non-opioid pain control options cont.’d – Anti-seizure medications: gabapentin & pregabalin
– Gabapentin
• MOA-unknown- does not cross BBB or bind to GABA receptors
• Research support for improved QOL such as ↑sleep, ↓pain duration, & ↓pain intensity
– Pregabalin
• MOA- ↓many neurotransmitters including substance P
• Research support for 30-60% ↓pain in dose range of 150-600mg/day, ↑sleep, ↓pain duration
HZ Treatment Strategy
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Opioids
• Challenges
• Who is a candidate?
• DIRE screening tool
• Tramadol & TCA
– Possible serotonin syndrome
Chronic Pain Rehab Programs
• Limitations
– Expense/lack of insurance coverage, decreased
availability, duration
• Holistic care
– PT/OT, nutrition, meditation, psychiatric health,
social support, life without opioids
• Goal
– Acceptance yet retained hope
– Take control over pain instead of opposite
HZ Treatment Strategy
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Interventional Procedures
Used with permission from
cartoonstock.com
Interventional Procedures
• Sympathetic nervous system (SNS) blockade
• Intercostal nerve block
• Paravertebral block
• Selective nerve root injection (transforaminal
approach)
• Radiofrequency ablation
• Intrathecal alcohol-high risk/last resort
• Alternative medicine approaches
Sympathetic blockade
• Interventional procedure goal
• Hypothesis & pathophysiology
• Direct and indirect SNS blockade
• Types of sympathetic block
• Epidural
• Stellate ganglion
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medication,
(2006). Rathmell, J.P. Lippincott Williams & Wilkins.
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Epidural SNS block
• Weekly blocks usually 3-5
• Initiation <3 months from pain onset
• Loss of resistance technique
• Fluoroscopy guided
• Anesthetic & steroid
• Affected side down ~30 min
• Monitor for hypotension
Stellate Ganglion Block
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medication,
(2006). Rathmell, J.P. Lippincott Williams & Wilkins.
Stellate Ganglion Block
• Sympathetic nervous system block-treats
trigeminal or ophthalmic HZ
• Earlier tx encouraged; <15d rash onset; weekly
treatments; ~6 = no pain at 6 months
• Delayed procedure for 6 months = only 50%
pain reduction; (placebo) no procedure = 13%
with persistent pain
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Intercostal Nerve Block
• Individual nerve block-
Tx acute HZ pain
• Two approaches
– “walk off” Inferior
margin of rib
– Posterior angle of the
ribs to access
paravertebral gutter
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medication,
(2006). Rathmell, J.P. Lippincott Williams & Wilkins.
Selective Nerve Root Injection
• Transforaminal
approach
– left or right
• Level of evidence:
case study reports only
• Cervical level is risky
Atlas of Image-Guided Intervention in Regional Anesthesia and Pain Medication,
(2006). Rathmell, J.P. Lippincott Williams & Wilkins.
Radiofrequency Ablation
• RF Burns dorsal root ganglia
• Prolonged pain relief
• Pulsed vs. continuous RF
• Epidural sympathetic ganglion block prior
• “positive diagnostic block”
• One pulsed RF case study; 50% ↓pain @12wks
• Not permanent
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Intrathecal alcohol
• Rare- high risk and last resort
• Alcohol destroys ganglion cells
• Potential undesired effects
– Paralysis
– Neuralgias
• One case study
Acupuncture
• Acupuncture (AC) research mixed results in
HZ/PHN pain tx
• RCT: AC vs. standard therapy (Italy, 2011)
• Outcome measures same, mean pain reduction
~4 points, +/- 2 on 10 point VAS at 4 weeks
• Limitations:
– study size; when tx initiated?
– Acupuncture research review: nearly 100% studies superiority
to western medicine = strong suspicion
Wet Cupping
• Chinese traditional medicine
(-) skin pressure by horn, glass or bamboo cups
• 8 types of cupping: empty, moving , wet,
moxa, needle, retained, herbal, & water
• Wet cupping (bleeding cupping)
• Two systematic reviews
• Mixed research support
• Significant bias potential
• Small Chinese studies only
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Implications for Wound Clinicians
• Natural history
• Strong evidence of substantial increases in HZ
across all age groups
• Incidence of shingles and its sequelae is
expected to increase as the US population ages
• Promotion of youth and adult vaccination
programs
• Differential diagnosis challenging
Implications for Wound Clinicians
• Acutely ill hospitalized patients are at
increased risk
• Definition of PHN (30 days, 3 months) unclear
• Pharmacologic management
• Severe pain or refractory to above = referral
• Subset of patients
Implications for Wound Clinicians
• Refer to interventional pain management <3
months onset or sooner if eye involvement
• Chronic pain programs
• Patients may choose complementary and
alternative treatments
• Insurance issues with management
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References
• Cao, H., Zhu, C., Lui, J. (2010). Wet cupping therapy for treatment of herpes zoster: a
systematic review of randomized controlled trials. Altern Ther Health Med, 16(6), 48-54.
• Centers for Disease Control and Prevention. (2011). Shingles Overview – Herpes Zoster.
http://www.cdc.gov/shingles/about/overview.html
• Klompas, M., Kulldorff, M., Vilk, Y. Bialek, S. R. & Harpaz, R. H. (2011). Herpes Zoster and
Postherpetic Neuralgia Surveillance Using Structured Electronic Data. Mayo Clinical
Proedures, (86),12, 1146-1153.
• Lee, M. S., Kim, J., & Ernst, E. (2011). Is cupping an effective treatment? An overview of
systematic reviews. J Acupunct Meridian Stud, 4(1), 1-4.
• Leung, J., Harpaz, R., Molinari, N-A., Jumaan, A., & Zhou, F. (2011). Herpes Zoster
Incidence Among Insured Persons in the United States, 1993-2006: Evaluation of Impact of
Varicella Vaccination. Clinical Infectious Diseases, 52(3), 332-340.
• Lukas, K., Edte, A., & Bertrand, I. (2012). The impact of herpes zoster and post-herpetic
neuralgia on quality of life: patient-reported outcomes in six European countries. J Public
Health, 20, 441-451. Doi: 10.1007/s10389-001-0481-8
• Mahamud, A., Marin, M., Nickell, S.P., Shoemaker, T., Zhang, J.X. & Bialek, S. R. (2012).
Herpes Zoster-Related Deaths in the United States: Validity of Death Certificates and
Mortality Rates, 1979-2007. Clinical Infectious Diseases, 55(7), 960-966.
References
• Makharita, M. Y., Amr, Y. M., & El-Bayoumy, Y. (2012). Effect of early stellate ganglion
blockade for facial pain from acute herpes zoster and incidence of postherpetic neuralgia.
Pain Physician Journal, 15, 467-474.
• National Center for Biotechnology Information. (2011). Shingles.
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001861/
• Rathmell, J.P. (2006). Atlas of image-guided intervention in regional anesthesia and pain
medicine. Philadelphia: Lippincott Williams & Wilkins.
• Shannon, H. J., Anderson, J., & Damle, J. S. (2012). Evidence for interventional procedures as
an adjunct therapy in the treatment of shingles pain. Advances in Skin & Wound Care, 25(6),
276-284.
• Ursini, T., Tontodonati, M., Manzoli, L. et al. (2011). Acupuncture for the treatment of severe
acute pain in Herpes Zoster: results of a nested, open-label, randomized trial in the VZV Pain
Study. BioMed Central Complementary and Alternative Medicine, 11(1), 46.
doi:10.1186/1472-6882-11-46
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