Applied Evidence

Stop shingles in its tracks

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Herpes zoster and its sequelae are painful, debilitating—and largely preventable. So why isn’t vaccination more widespread?


 

References

PRACTICE RECOMMENDATIONS

Initiate antiviral treatment as soon as possible; rapid resolution of acute pain and reduction in the development of postherpetic neuralgia (PHN) are most likely when therapy is started within 72 hours of the outbreak. A

Discuss herpes zoster (HZ) vaccination with healthy patients 60 years of age and older during their first office visit; the vaccine markedly reduces the incidence of HZ and PHN. A

Do not prescribe tricyclic antidepressants or corticosteroids in the acute phase of HZ. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

We don’t do enough to protect our patients from the pain of herpes zoster (HZ). Consider:

  • Each year in the United States, about 1 million new cases of herpes zoster (HZ) occur.1 The incidence is estimated at 3 to 4 per 1,000 in the general population,2 but climbs to more than 10 per 1000 among people 60 years of age and older.3,4
  • Overall, between 13% and 26% of patients with HZ develop postherpetic neuralgia (PHN), defined as pain that continues for more than 1 month after the rash has healed. Among patients who are 70 or older, however, the likelihood that HZ will progress to PHN is approximately 50%.5 (In a study of 7595 patients being treated for HZ or PHN by general practitioners or dermatologists in France, 45% reported pain that was severe or very severe, and 42% reported permanent pain.6 )
  • Between 10% and 25% of HZ patients develop ocular complications, which have the potential to result in vision loss, facial scarring, or prolonged or permanent pain.7 Encephalitis, myelitis, and peripheral nerve palsies are potential complications, as well.

Yet HZ and its complications are largely preventable.

A live attenuated vaccine (Zostavax) received US Food and Drug Administration approval in 2006.8 But many patients have not yet heard of it, and many physicians fail to recommend it. (See “Herpes zoster vaccine: Why aren’t more people receiving it?”.)

As a family physician, you can play a key role in reducing the burden of shingles by rapidly identifying and treating HZ, minimizing the risk of prolonged pain, and, notably, by talking to older patients about the benefits of vaccination.

Herpes zoster vaccine: Why aren’t more people receiving it?

Zostavax, a live attenuated herpes zoster (HZ) vaccine, was licensed by the US Food and Drug Administration in 2006 for use in people 60 years of age and older—the first new vaccine targeting this age group in years. In 2007, researchers at the Centers for Disease Control and Prevention (CDC) conducted a national survey,20 in part to gauge the knowledge of, and interest in, the HZ vaccine among the intended recipients.

Their findings: Of more than 3500 respondents, only 1.9% had received the HZ vaccine. Most (72%) were unaware of the vaccine’s existence, but the majority said they would agree to vaccination if their physician were to recommend it.

Among those who were aware of it, the key reasons for rejecting the vaccine were that it was not needed (cited by 35%), they were not at risk (13%), and a lack of trust in doctors or the US health care system (10%). Both the limited awareness of the vaccine and the lack of physician recommendations are barriers to HZ vaccination, the researchers concluded.20

On its Web site, the CDC broaches another potential barrier to greater use of the HZ vaccine: cost. The vaccine is not covered by Medicare Part B, nor by some private insurers. While it is covered by all Medicare Part D plans, the extent of coverage depends on the particular plan. The CDC recommends that physicians encourage patients to contact their insurers to determine the extent of their coverage.21

Start antiviral therapy without delay

Several meta-analyses and many (though not all) randomized controlled trials (RCTs) of HZ treatment have demonstrated that prompt antiviral therapy—with oral acyclovir (ACV), valacyclovir (VCV), or famciclovir (FCV)—reduces the duration of acute pain and the likelihood that PHN will develop.9,10 Without antiviral therapy, up to 45% of patients over the age of 60 experience pain that persists for 6 months to a year. Even with therapy, studies have found that about 20% of patients older than 50 years continued to have pain for 6 months after their rash appeared.10 Risk factors for PHN include age (>50 years), sex (female), a disseminated rash, a severe pain presentation, and polymerase chain reaction-detectable varicella zoster virus viremia.11

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