Shingles: Using Interventional Treatment Therapies to Treat Post- Herpetic Neuralgia Julie W. Anderson, PhD, RN Heidi J. Shannon, MS, FNP-BC

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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 Reactivation of virus Varicella zoster Dormant in dorsal Root ganglia Susceptibility Varicella Varicella vaccine Reoccurrence Clinical Overview 1

2 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. 2

3 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) 3

4 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 wellbeing, 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 4

5 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 5

6 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 6

7 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 mg/day, sleep, pain duration HZ Treatment Strategy 7

8 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 8

9 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. 9

10 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 10

11 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% Not permanent 11

12 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 12

13 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 13

14 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), Centers for Disease Control and Prevention. (2011). Shingles Overview Herpes Zoster. 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, 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, : Evaluation of Impact of Varicella Vaccination. Clinical Infectious Diseases, 52(3), 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, Doi: /s 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, Clinical Infectious Diseases, 55(7), 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, National Center for Biotechnology Information. (2011). Shingles. 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), 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: / Questions? 14