shingles: using interventional treatment therapies to ... · shingles: using interventional...

9/16/2013

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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



• 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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• 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


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• 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


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


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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


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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



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



Selective Nerve Root Injection

• Transforaminal

approach

– left or right

• Level of evidence:

case study reports only

• Cervical level is risky



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


• 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


• 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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