Nerve blocks combined with tricyclic antidepressants gave rapid relief of pain in 80% cases in one Japanese report. I feel nerve blocks or epidural blocks are manditory for any cases of shingles in which the current acutely infected pain would be too high to live with long-term.
Masui. 2008 Jul;57(7):874-8. [Effective treatment of acute pain and related symptoms in elderly with herpes zoster] [Article in Japanese] Tajima K, Kawagoe I, Kanai M, Mitsuhata H.
Found tricyclic antidepressants (TCA) like Amitriptyline and nerve blocks alleviated acute pain in 80% of cases and relief of depressive symptoms with it. TCA dose -?anyone read Japanese?
abstract here
This approach was reiterated by another oriental article published last year:
Acta Anaesthesiol Taiwan. 2007 Jun;45(2):95-101. Clinical experience of pain treatment for postherpetic neuralgia in elderly patients. Chau SW, Soo LY, Lu DV, Chen TI, Cheng KI, Chu KS.
“CONCLUSIONS: Our study results showed that the concurrent combination therapy with proper medications and appropriate nerve blocks could offer satisfactory pain relief in the majority of elderly patients with PHN. ”
abstract here
- Anticonvulsants – all got gabapentin
- NSAID’s – some
- Opioids – 98.3%. For elderly, I like to start with Tramadol – I like tramacet (tramadol plus acetaminophen) plus a longer acting form of tramadol at bedtime.
ZYTRAM XL pdf here
Tridural pdf here
Ralivia (Canada) or ULTRAM® ER(USA) pdf here
Yet one study found Oxycodone useful when other agents failed:
Case Reports: Zoster Pain in Haematological Malignancies: Effective Pain Relief with Oxycodone in Patients Unresponsive to Other Analgesic Measures
Pasquale Niscola1, Alessio Pio Perrotti1, Giovanni del Poeta1, Claudio Romani2, Massimiliano Palombi1, Daniela Piccioni1,Laura Scaramucci1, Barbara Tolu1, Andrea Tendas1, Luca Cupelli1, Elisabetta Abruzzese1, Gianna Maria D’Elia3, Gregorio Antonio Brunetti3, Luca Maurillo1, Marco Giovannini4, Claudio Cartoni3 and Paolo de Fabritiis
HERPES 14:2 2007; p45-47whole article here
- “Nerve block with 0.25% bupivacaine or 1% lidocaine twice a week at the beginning of the treatment.” – in 84.5% of cases this meant intercostal nerve blocks
Review:
1) Nerve blocks have been known to give rapid relief of shingles pain for years.
Chronic neuralgia incidence following local anesthetic therapy for herpes zoster
J. M. Riopelle, M. Naraghi and K. P. Grush
Archives of Dermatology Vol. 120 No. 6, June 1984
abstract here
They found in their severe cases they could achieve rapid pain relief; they hedged on the thought it could help post-herpetic neuralgia though with the rapid relief of pain one would find that incongruous. It is possible you can’t make a cake with just flour – in this cases, you may need to repeatedly inject tissues with local and steroid to cut the peripheral sensitization down and use amitriptyline to counter central sensitization and engage descending inhibitory pain circuits. Gabapentin/ Lyrica alternatively.
Very little had been written specially about nerve blocks until a Canadian Journal of Anesthesia article in 2005 – It was again noted to cause rapid resolution of pain in severe cases and a plea to use them.
Canadian Journal of Anesthesia 52:186-190 (2005)
Relief of pain in acute herpes zoster by nerve blocks and possible prevention of post-herpetic neuralgia
Douglas Hardy, MD FRCPC
whole article here
2) The value of sympathetic nerve blocks was well established.The role of sympathetic nerve blocks in herpes zoster and postherpetic neuralgia
Christopher L. Wua, Ann Marshb, Robert H. Dworkinc
Pain 87 (2000) 121-129
here
This includes use of stellate blocks in facial zoster. I had to show this article to an anesthetist before he was willing to do this block on one elderly patient in agony. I had tried infraorbital blocks which did help but were locally too painful to repeat. A 32 gauge needle might have helped here.
Ann Ophthalmol. 1991 May;23(5):188-9. Treatment for herpes zoster ophthalmicus: stellate ganglion block as a treatment for acute pain and prevention of postherpetic neuralgia. Currey TA, Dalsania J.
3) Epidural +/- steroid is well demonstrated moreso and there is a TWO MONTHS window:
Reg Anesth Pain Med. 2004 Sep-Oct;29(5):454-61.
Neuraxial and sympathetic blocks in herpes zoster and postherpetic neuralgia: an appraisal of current evidence.
Kumar V, Krone K, Mathieu A.
“CONCLUSIONS:
- Evidence for the beneficial effect of epidural LA [local anesthetic] + steroid in HZ, and intrathecal LA + steroid in PHN appears to be consistent (grade A).
- If given within 2 months of HZ, epidural LA + steroid may reduce the incidence of PHN after 1 year (grade A).
- Evidence for use of sympathetic blocks in HZ and PHN, although generally useful (Grade B), requires RCTs for validation.”
The Effects of Epidural Blockade on the Acute Pain in Herpes Zoster
Sang Min Hwang, MD; Yun Chul Kang, MD; Young Bok Lee, MD; Kyung Bong Yoon, MD;
Sung Ku Ahn, MD, PhD; Eung Ho Choi, MD, PhD
Arch Dermatol. 1999;135:1359-1364 whole article
4) Oral medications include:
- famciclovir (famvir) 250 mg, three times a day, given orally for 7 days –
J Eur Acad Dermatol Venereol. 2005 Jan;19(1):47-55. Brivudin compared with famciclovir in the treatment of herpes zoster: effects in acute disease and chronic pain in immunocompetent patients. A randomized, double-blind, multinational study. Wassilew S
Valacyclovir (Valtrex) is converted to acyclovir. 1 gm three times daily for 7 days ($250.00) was compared with 2 gm three times daily for 7 days ($500.00). The latter would give IV aclyclovir levels which might be important in delayed treatment cases (see other blog writeup). They compared both dosages in immunocompromised cases and got similar results.:
“Participants in both arms of the study demonstrated similar median times to full crusting of the rash (8 days), and both dosages were safe and effective therapies for reduction of ZAP [Zoster Associated Pain] and ZAAS [Zoster Associated Abnormal sensations] in the immunocompromised patient population”
Infect Dis. 2008 May 1;197(9):1289-95. Double-blind study comparing 2 dosages of valacyclovir hydrochloride for the treatment of uncomplicated herpes zoster in immunocompromised patients 18 years of age and older. Arora A, Mendoza N, Brantley J, Yates B, Dix L, Tyring S.