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How to Treat Shingles?

  • July 26, 2023
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How to Treat Shingles?

Things to note:
  • Isolate from immunocompromised or pregnant non-immune individuals (who may develop severe chickenpox).
  • Offer HIV test especially in patients < 50 years of age.
Medical Treatment:
Antiviral therapy, for:
  • zoster in immunocompromised patients, provided that active lesions are still being formed, and
  • in immunocompetent individuals provided they present within 72 hours of onset.
  • Aciclovir, oral, 800 mg five times daily for 7 days (4 hourly missing the middle of the night dose).
For zoster with secondary dissemination or neurological involvement:
  • Aciclovir, IV, 10 mg/kg administrerd over one hour 8 hourly for 7 days.
    • The course can be completed with oral aciclovir 800 mg five times daily.
Eye involvement:
  • Aciclovir opthalmic ointment 3%, applied into lower conjunctival sac, five times daily.
Secondary infection
  • This is seldom present and is over-diagnosed.
  • The vesicles in shingles often contain purulent material, and erythema is a cardinal feature of shingles.
  • If there is suspected associated bacterial cellulitis:
    • Flucloxacillin, oral, 500 mg 6 hourly for 5 days.
  • Pain is often very severe and requires active control.
  • Combination of different classes of analgesics is often necessary.
  • Recommended therapy for acute phase of infection, e.g:
    • Paracetamol, oral, 1 g 4-6 hourly when required to a maximum of 4 doses per 24 hours.
If pain is not adequately controlled:
  • Tramadol, oral, 50 mg 6 hourly
  • Although pain is rarely eliminated, treatment should reduce daily pain level, as well as the frequency, severity and duration of the pain flares.
  • Neuropathic pain is best treated with amitriptyline. If this fails, consider the use of antiepileptics, e.g. carbamazepine or a weak opiate, e.g. tramadol. Concerns regarding addiction should not compromise adequate pain control with opioids.
  • Utilise the least invasive route of medication administration, preferably oral.
  • For chronic pain, analgesics must be administered regularly and not only when required (prn).
  • Additional short-acting analgesia may be required 30 minutes prior to paininducing activity such as physiotherapy.
  • Combinations of medications from different classes may have additive analgesic effects.
Non-opioid drugs:
  • Paracetamol, oral, 1 g 6 hourly.
If no response, add non-steroidal anti-inflammatory drugs (NSAIDs).
NSAIDs, e.g:
  • Ibuprofen, oral, 400-800 mg 8 hourly with meals.
    • An additional night-time dose of a NSAID may be required.
    • Can be used in combination with paracetamol or opioids.
  • There are safety concerns with the long-term use of NSAIDs, including increased risk of CVS disease, renal impairment and GIT bleeding.
  • If no response, add opioid drugs.
  • Increase doses of opioids according to the individual need to overcome pain.
  • Take into account the development of tolerance.
  • In chronic pain, the correct dose is that which relieves the patients symptoms and, except for tramadol, may exceed the recommended dose used in other pain relief settings.
  • Tramadol, oral, 50 mg, 6 hourly as a starting dose.
    • May be increased to a maximum of 400 mg daily.
  • Morphine BP, short-acting solution, oral.
    • Starting dose: 20 mg 4 hourly.
    • Elderly, frail or patients less than 50 kg: 10 mg 4 hourly.
    • Increase dose by 50 % every dosage interval if pain control is sub-optimal.
    • Reduce the dosing interval if there is regular breakthrough pain.
  • Morphine, long-acting, oral, 30-60 mg 12 hourly.
    • Titrate to desired effect.
  • Manage nausea caused by opioids.
For constipation caused by opioids:
  • Sennosides A and B, oral, 2 tablets at night.
For constipation in patients with potentially obstructive lesions:
  • Lactulose, oral, 15 mL 12 hourly.
Adjuvant therapy
Adjuvant agents can enhance pain control by targeting specific pain mechanisms:
  • Nerve injury pain,
  • Burning paraesthesia,
  • Neuropathic pain,
  • Nerve root compreBetaion,
  • HIV neuropathy,and
  • Chemotherapeutic nerve injuries.
In addition to analgesia as above:
  • Amitriptyline, oral, 10 mg at night.
  • Titrate up to 75 mg at night.
  • Carbamazepine, oral, 100 mg 12 hourly for 2 weeks.
    • Then 200 mg 12 hourly.
    • Titrate dose slowly up to 600 mg every 12 hours, depending on the response.
For nausea and vomiting:
  • Metoclopramide, oral, 10-20 mg 8-12 hourly.
  • Metoclopramide, IV or IM, 10 mg 8 hourly.
For pruritus or nausea:
  • Promethazine, oral/IV, 10 mg 6 hourly.
For anxiety:
  • Diazepam, oral, 2-5 mg 12 hourly.
For colic:
  • Hyoscine butylbromide, IV/oral, 10 mg 8 hourly.
Post-herpetic neuralgia:
  • Initiate treatment with adjuvant therapy early.
  • Amitriptyline, oral, 25 mg at night.
    • Titrate as necessary to a maximum of 75 mg.
When to refer:
  • To an ophthalmologist if there is ocular involvement with ophthalmic zoster (if the tip of the nose is involved then suspect ocular involvement)
  • Positive Hutchinson sign, i.e. vesicle at the tip/side of the nose.
  • Fluorescein staining of cornea (keratitis/ulceration).
  • Decreased vision, i.e. a 2 line fall off in Snellen acuity in affected eye compared to healthy eye or afferent pupil defect.
  • Red eye (uveitis or keratitis).
  • Cranial nerve palsies.

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