How to Treat Shingles?
- July 26, 2023
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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.
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).
- 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.
ADD
- Aciclovir opthalmic ointment 3%, applied into lower conjunctival sac, five times daily.
- 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.
- Paracetamol, oral, 1 g 6 hourly.
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.
- Sennosides A and B, oral, 2 tablets at night.
- Lactulose, oral, 15 mL 12 hourly.
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.
- 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.
- Metoclopramide, oral, 10-20 mg 8-12 hourly.
- Metoclopramide, IV or IM, 10 mg 8 hourly.
- Promethazine, oral/IV, 10 mg 6 hourly.
- Diazepam, oral, 2-5 mg 12 hourly.
- Hyoscine butylbromide, IV/oral, 10 mg 8 hourly.
- Initiate treatment with adjuvant therapy early.
- Amitriptyline, oral, 25 mg at night.
- Titrate as necessary to a maximum of 75 mg.
- 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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