HZ-related Pain Research Articles

8. Herpes zoster and post herpetic neuralgia.

Patients suffering from postherpetic neuralgia (PHN) report unilateral chronic pain in one or more dermatomes after an acute herpes zoster (HZ) infection. The incidence of acute HZ ranges between three and five patients per 1000 person-years. In one out of four patients, acute HZ-related pain will transition into PHN. PHN can be very disabling for patients and reduce quality of life. Additionally, the treatment of PHN is characterized by high failure rates. The aim of this review is to give an update on the previous practical guideline published in 2011 and revised in 2015 (published in 2019) and to provide an overview of current interventional treatment options for HZ infection and PHN. The literature on the diagnosis and treatment of HZ and PHN was systematically reviewed and summarized. The most important treatment for acute HZ-related pain is antiviral therapy within 72 h of symptom onset. Additional symptomatic treatment options are analgesic drugs according to the WHO pain ladder, tricyclic antidepressants (eg, nortriptyline), and antiepileptic drugs (eg, gabapentin). If pain is not sufficiently reduced, interventional treatment such as an epidural injection with local anesthetics and corticosteroids or pulsed radiofrequency of the dorsal root ganglion (DRG) are options. Treatment for PHN is preferably transdermal capsaicin, lidocaine, or oral drugs such as antidepressants or antiepileptics. Treatment of acute HZ-related pain especially PHN is challenging. Besides the conventional treatment for PHN, interventional management is considered a new treatment option. PRF of DRG seems to be the most promising interventional management.

Efficacy and Safety of Pulsed Radiofrequency of Dorsal Root Ganglion in Elderly Patient Population With Acute and Subacute Zoster-Related Pain.

Background: Herpes zoster (HZ) is typically characterized by a burning, stabbing pain, hyperalgesia, and allodynia. In some patients, despite the lesions resolving, the pain persists and becomes chronic. If the pain continues for more than 6 months after the onset of the pain phase, this condition is called postherpetic neuralgia (PHN). The frequency and severity of PHN increase with advancing age. The pain in PHN can be severe, sometimes resistant to medications, significantly impacting the patients' quality of life. The elderly patient population cannot tolerate the medications due to their side effects. In this situation, interventional pain treatment should be applied in the elderly patient group who have a high risk of developing PHN compared to other age groups. Method: We included patients over 65 years of age with HZ-related pain who underwent dorsal root ganglion (DRG) pulsed radiofrequency (PRF) within the first 6 months from the onset of pain. We divided these patients into 2 groups: patients who underwent intervention within the first 1 month from the onset of pain and patients who underwent intervention between 1 and 6 months. We recorded medication doses and Numeric Rating Scale (NRS) scores before the procedure and at 1 week, 1 month, 3 months, and 6 months after the procedure. Results: After the DRG PRF treatment, NRS scores improved significantly in both groups (p < 0.05). The mean NRS score in the early DRG PRF group was significantly lower than that in the late DRG PRF group (p < 0.05). The medication doses in the early DRG PRF group were significantly lower than those in the other group (p < 0.05). Conclusions: Interventional pain treatment should be applied as soon as possible in the elderly patient group who do not respond to first-line medical treatment or cannot tolerate medical treatment due to its side effects and who have a high risk of developing PHN compared to other age groups. DRG PRF, applied in the early period of medical treatment-resistant acute HZ, is safe and effective, preventing the progression to PHN.

Incidence and Burden of Herpes Zoster in Sweden: A Regional Population-Based Register Study.

Herpes zoster (HZ) is a painful disease that mainly affects individuals whose immune system has been weakened because of increasing age (> 50years) or certain diseases or treatments. We estimated the complete burden of HZ. This population-based register study analysed healthcare data from the VEGA and Digitalis databases of Västra Götaland Region (VGR), Sweden. The VEGA database includes all patients in VGR, covering both hospital and primary care. The Digitalis records prescribed medications. The study population included patients aged ≥ 18years with at least one registered primary or secondary HZ diagnosis (based on International Classification of Diseases [ICD] codes) between 2005 and 2021. Incidence rates (95% confidence intervals [CI]) were stratified by age, sex and diagnosis/analgesic prescription. Overall HZ incidence increased from 2.5 (95% CI 2.4-2.6) in 2005 to 4.2 (95% CI 4.1-4.3) in 2021. The increase in incidence was rapid from 2005 to 2013, followed by a plateauing trend. From 2014-2019, the lifetime risk of HZ, excluding recurrent cases, was 36.5% (95% CI 35.5-37.4%). Municipal differences ranged from 34.4% (95% CI 32.5-36.4%) to 43.6% (95% CI 39.9-47.4%). Recurrence rates of HZ were 8.7% and 9.1% with follow-up periods of 5.5 and 10.5years, respectively. Reported postherpetic neuralgia (PHN) cases increased five-fold over the study period. In 2019, 19% of all HZ patients developed HZ-related neuropathic pain; 13.6% had signs of persistent pain (> 90days; i.e. PHN). An increased occurrence of cerebral and cardiovascular disease was observed in HZ patients. Among high-risk groups the occurrence of HZ peaked among those with inflammatory and autoimmune diseases. HZ and PHN risk in Sweden is comparable to that in other European countries prior to implementing HZ national vaccination programs. Municipal differences suggest that the lifetime risk of HZ in Sweden is at least 36.5%. NCT Number ( www. gov ).

911. Burden of Herpes Zoster among Employed Adults in the Department of Veterans Affairs Health System

Abstract Background Herpes zoster (HZ) is characterized by a painful dermatomal rash and is associated with increased healthcare costs. Research quantifying work productivity loss and activity impairment associated with HZ is limited and outdated. This study aimed to describe severity of HZ related pain, health related quality of life, activity impairment, and work productivity among employed adults diagnosed with HZ in the Department of Veterans Affairs (VA) Health System. Methods This cross-sectional study utilized a self-reported survey among adults in the VA health system. Eligibility was assessed biweekly from electronic health record data, and adults with an incident International Classification of Diseases, 10th Revision (ICD-10) HZ diagnosis were invited to complete an online survey. Respondents were indexed on their HZ diagnosis and included if aged 18-70 years, reported working for pay at index, and had 6 months of baseline continuous enrollment. Respondents were excluded if they had a baseline HZ vaccine, did not complete the survey within 30 days after index, or reported not having HZ or experiencing a rash &amp;gt; 14 days prior to index. Questions used to assess outcomes were based on validated survey instruments (Table 1). Work productivity was described among respondents employed at survey completion. Data were collected from 05/04/2021 to 07/07/2022. Descriptive statistics were used to summarize survey responses. Results Among 231 respondents completing the survey, mean (standard deviation [SD]) age was 49 (10) years and 79% were male. Overall, 70% reported experiencing pain in the last 7 days. Mean (SD) [minimum, maximum] “average-pain” severity and EQ-5D-3L scores were 4.0 (2.8) [0, 10] and 0.69 (0.22) [-0.04, 1.00], respectively. Mean (SD) activity impairment was 42% (33%). Mean (SD) absenteeism, presenteeism, and overall work impairment were 17% (27%), 35% (30%), and 43% (35%) out of 202, 192, and 202 respondents, respectively. Conclusion Burden associated with HZ is substantial, with a significant proportion experiencing pain, activity impairment, and work productivity loss. These results provide updated context on the impact of HZ in this population of employed adults in the VA health system. Funding: GlaxoSmithKline Biologicals SA (GSK study identifiers: 208907/HO-16-16967). Disclosures Shaloo Gupta, MS; ORCID: 0000-0002-2535-2892, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Nai-Chung N. Chang, PhD; ORCID: 0000-0002-4541-8967, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Nikita Stempniewicz, MSc, GSK: Salary|GSK: Ownership Interest Chenchu Bhavani K. Tirupati, MS, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Gregorio Coronado, MBA, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Kantar Health: Grant/Research Support|Myriad Genetic Laboratories, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Julie A. Lynch, PhD, RN, MBA; ORCID: 0000-0003-0108-2127, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support Cosmina Hogea, PhD; ORCID: 0000-0002-0686-2395, Gilead Sciences: Ownership Interest|GSK: Salary at the time of the submitted work|GSK: Ownership Interest Emily Mulvihill, MBA; ORCID: 0000-0002-1430-8837, Cerner Enviza: Salary|GSK: Funding to employer to conduct and support this study Scott L. DuVall, PhD, Alnylam Pharmaceuticals, Inc.: Grant/Research Support|Astellas Pharma, Inc.: Grant/Research Support|AstraZeneca Pharmaceuticals LP: Grant/Research Support|Biodesix: Grant/Research Support|Celgene Corporation: Grant/Research Support|Cerner Enviza: Grant/Research Support|GSK: Grant/Research Support|Janssen Pharmaceuticals, Inc.: Grant/Research Support|Novartis International AG: Grant/Research Support|Parexel International Corporation: Grant/Research Support

Burden of opioid use for pain management among adult herpes zoster patients in the US and the potential impact of vaccination

ABSTRACT The goal of this research was to describe treatment patterns, health-care resource utilization, and costs for herpes zoster (HZ)-related pain, and to estimate the potential impact of recombinant zoster vaccine (RZV) on avoided HZ cases and HZ-related pain prescriptions. This retrospective claims database study included patients from commercial, Medicare, and Medicaid plans between 2012 and 2017. Subjects with an HZ episode were assigned to three cohorts: “opioid”, “non-opioid”, and “no-treatment” cohorts. Subjects in the opioid cohort were matched to a non-HZ cohort. The potential impact of RZV vaccination on HZ case avoidance and resulting painkiller prescriptions was modeled. Over 25% of subjects with an HZ episode received opioids. Adjusted health-care costs were approximately double in the opioid cohort versus non-opioid or matched non-HZ cohorts. Postherpetic neuralgia, immunocompromised status, and comorbidities increased the risk for opioid prescription. RZV vaccination was predicted to avoid over 19,000 patients from receiving opioid prescriptions for every 1 million adults aged ≥50 years. HZ-related prescriptions of opioids were common and led to increased health care costs. RZV vaccination may potentially reduce opioid prescriptions through decreasing HZ incidence.

Economic Burden and Impact on Quality of Life of Herpes Zoster in Spanish Adults Aged 50Years or Older: A Prospective Cohort Study.

IntroductionThe economic burden of herpes zoster (HZ), including its most common complication, postherpetic neuralgia (PHN), and its impact on health-related quality of life (HRQL) is not well described in Spain. The aim of this study was to estimate HZ-related healthcare costs and impact on HRQL in Spanish adults aged 50 years or older.MethodsA prospective, observational study was performed with patients with HZ recruited through four general practitioner networks in Spain (NCT01521286). HRQL data were collected using the EuroQoL-5 Dimension (EQ-5D) questionnaire; HZ-related pain and associated interference with activities of daily living (ADL) were assessed using the Zoster Brief Pain Inventory (ZBPI) questionnaire at days 0 (HZ rash onset), 15, 30, 60, and 90; patients with PHN were assessed up until day 270. Medical resource utilization was recorded throughout study follow-up. Work loss for patients/caregivers was also assessed. Costs were calculated from both the payer and societal perspectives.ResultsA total of 545 patients with Hz were included, of whom 25 developed PHN. During days 0–30 post HZ diagnosis, the mean EQ-5D utility score was 0.738, equating to a utility loss of 0.138. Sleep was the ADL most affected component. The mean costs for HZ in the overall cohort were €240 and €296 from the payer/societal perspective, respectively; €187/€242 for patients with HZ without any HZ-related complications; and €571/€712 for patients who developed PHN. The majority of costs were incurred during days 0–30.ConclusionsIn Spain, HZ and HZ-related complications such as PHN reduce patient HRQL and increase the economic burden for both payers and society in general.Trail RegistrationClinicalTrials.gov identifier NCT01521286.Supplementary InformationThe online version contains supplementary material available at 10.1007/s12325-021-01717-7.

7. Can Recombinant Zoster Vaccine Administration Decrease the Use of Herpes Zoster-related Pain Medication Across Randomized Controlled Studies?

BackgroundOlder and immunocompromised adults are at increased risk for herpes zoster (HZ) and often experience persistent, severe HZ-related pain, impacting their quality of life and activities of daily living. High vaccine efficacy (VE) of the adjuvanted recombinant zoster vaccine (RZV) in preventing HZ and reducing severe and clinically significant HZ-related pain has been shown in adults ≥ 50 years of age (YOA; ZOE-50 study; NCT01165177), ≥ 70 YOA (ZOE-70; NCT01165229) and ≥ 18 YOA undergoing autologous hematopoietic stem cell transplantation (ZOE-HSCT; NCT01610414).MethodsIn patients with confirmed HZ from the above phase III, randomized, placebo-controlled studies, we analyzed VE of RZV in reducing the duration of clinically significant HZ-related pain and in reducing the use and duration of HZ-related pain medication. Pain was assessed by the Zoster Brief Pain Inventory (ZBPI). Use of all HZ-related medication was recorded.ResultsVE in reducing the duration of clinically significant HZ-related pain (ZBPI pain score ≥3) during HZ episodes was 38.5% (p-value: 0.0099) in RZV-vaccinated patients from the ZOE-HSCT study compared to placebo. A similar trend (not statistically significant) was observed in the ZOE-50 (VE: 26.9%; p-value: 0.4318) and ZOE-70 (VE: 28.4%; p-value: 0.1877) studies. VE in reducing the use (Table 1) and duration (Table 2) of HZ-related pain medication was 39.6% (p-value: 0.0083) and 49.3%(p-value: 0.0404), respectively, in the ZOE-70 study; corresponding positive VE estimates were also seen in the ZOE-50 and ZOE-HSCT studies. Non-opioids were used by 61.2%, 44.3% and 22.1% of patients in the ZOE-50, ZOE-70 and ZOE-HSCT studies, respectively; weak opioids by 18.6%, 13.0% and 10.8% of patients, and strong opioids by 8.0%, 2.0% and 5.3% of patients (Table 3).Table 1. Reduction in the use of HZ-related pain medication in patients with confirmed HZ Table 2. Reduction in the duration of HZ-related pain medication use in patients with confirmed HZ Table 3. HZ-related medication types in patients with confirmed HZ ConclusionIn addition to a high VE in preventing HZ in these studies, we also observed an attenuation of HZ-related pain, and thus lower use and duration of pain medication in breakthrough cases after RZV vaccination, thereby potentially improving patient quality of life. Funding: GlaxoSmithKline Biologicals SA Acknowledgment: Kristel Vercauteren/Sander Hulsmans (Modis c/o GSK) provided medical writing/editorial supportDisclosures Joon Hyung Kim, MD, GSK (Employee, Shareholder) Robert Johnson, MD, FRCA, GSK (Other Financial or Material Support, I accept no fees but have had expense reimbursement in the past.) Martina Kovac, MD, GSK (Other Financial or Material Support, I was an employee of GSK at the time of the study) Anthony L. Cunningham, MBBS, MD, FRACP, FRCPA, GSK (Consultant) Srikanth Emmadi, MSc, GSK (Employee) Keith Sullivan, MD, FASTCT, GSK (Consultant) Alemnew F. Dagnew, MD, GSK group of companies (Employee, Shareholder) Desmond Curran, PhD, GSK (Employee, Shareholder) Anne Schuind, MD, GSK (Employee, Other Financial or Material Support, own GSK stock options or restricted shares as part of renumeration)

Department of Physical Medicine and Rehabilitation, University of Health Sciences, Fatih Sultan Mehmet Education and Training Hospital, Istanbul, Turkey

Background: Postherpetic neuralgia (PHN) occurs in 9% to 34% of herpes zoster (HZ) patients, and the incidence of PHN is positively correlated with age. A number of patients suffer from poor therapeutic effects or intolerable side effects and need to accept minimally invasive analgesia. Objectives: This study aimed to investigate the effects of spinal cord stimulation (SCS) and pulsed radiofrequency (PRF) on the treatment of elderly patients with HZ-related pain persisting beyond the acute phase. Study Design: A prospective, randomized-controlled trial. Setting: Research was conducted at the National Pain Management and Research Center, ChinaJapan Friendship Hospital (Beijing, China). Methods: We selected 63 patients aged over 50 years with zoster-related pain of 1 to 6 months onset. They were randomly divided into an SCS group and a PRF group. In the SCS group, the stimulus electrodes were placed in the affected spinal ganglion segment of the epidural space for 2 weeks. In the PRF group, the radiofrequency needle was percutaneously punctured in the affected dorsal root ganglion. The main outcome measures were the Numeric Rating Scale (NRS-11) score, response rate, and complete remission rate. The secondary endpoint was defined as the use of analgesics and calcium channel antagonists. Results: The NRS-11 score in the SCS group decreased to 2.90 ± 1.83 (1 week post operation) and 4.37 ± 2.43 (24 weeks post operation), while that in the PRF group decreased to 3.13 ± 1.78 and 4.23 ± 2.64, respectively (compared with baseline, P &lt; .001); there was no significant difference between the 2 groups (P &gt; .05) . The effective rate of pain management was in the range of 56.67% to 81.25%, and the complete pain relief rate ranged from 37% to 71%. The number of patients still using analgesics and calcium channel antagonists after operation were significantly less than those pre-operation (P &lt; .001). Univariate and multivariate logistic regression analyses showed that the operation method, age, gender, and course of disease did not affect surgical efficacy. Limitations: The main limitation of this study is that all the cases were from the same center. Conclusion: It therefore can be concluded that SCS and PRF can effectively relieve PHN. Key words: Spinal cord stimulation, pulsed radiofrequency, postherpetic neuralgia

Characterizing the Structural Pattern Predicting Medication Response in Herpes Zoster Patients Using Multivoxel Pattern Analysis.

Herpes zoster (HZ) can cause a blistering skin rash with severe neuropathic pain. Pharmacotherapy is the most common treatment for HZ patients. However, most patients are usually the elderly or those that are immunocompromised, and thus often suffer from side effects or easily get intractable post-herpetic neuralgia (PHN) if medication fails. It is challenging for clinicians to tailor treatment to patients, due to the lack of prognosis information on the neurological pathogenesis that underlies HZ. In the current study, we aimed at characterizing the brain structural pattern of HZ before treatment with medication that could help predict medication responses. High-resolution structural magnetic resonance imaging (MRI) scans of 14 right-handed HZ patients (aged 61.0 ± 7.0, 8 males) with poor response and 15 (aged 62.6 ± 8.3, 5 males) age- (p = 0.58), gender-matched (p = 0.20) patients responding well, were acquired and analyzed. Multivoxel pattern analysis (MVPA) with a searchlight algorithm and support vector machine (SVM), was applied to identify the spatial pattern of the gray matter (GM) volume, with high predicting accuracy. The predictive regions, with an accuracy higher than 79%, were located within the cerebellum, posterior insular cortex (pIC), middle and orbital frontal lobes (mFC and OFC), anterior and middle cingulum (ACC and MCC), precuneus (PCu) and cuneus. Among these regions, mFC, pIC and MCC displayed significant increases of GM volumes in patients with poor response, compared to those with a good response. The combination of sMRI and MVPA might be a useful tool to explore the neuroanatomical imaging biomarkers of HZ-related pain associated with medication responses.

Patient report of herpes zoster pain: Incremental benefits of zoster vaccine live

IntroductionPain following herpes zoster (HZ) can persist for months and negatively impact quality of life. To evaluate the effect of zoster vaccine live (ZVL) on progression of pain following HZ, we conducted a prospective cohort study of HZ cases at Kaiser Permanente Southern California. MethodsZVL vaccinated and unvaccinated members aged ≥60 years with laboratory-confirmed HZ from January 18, 2012 to February 26, 2015 were followed up within 5 days of HZ diagnosis, and at 30, 60, and 90 days after diagnosis. Pain was assessed with the Zoster Brief Pain Inventory (ZBPI) on a 0–10 scale, using cut-points of ≥3, ≥5, and ≥7, with postherpetic neuralgia (PHN) defined as pain ≥3 at 90 days. Log binomial regression was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) associated with pain, comparing vaccinated versus unvaccinated HZ patients. ResultsWe interviewed 509 vaccinated and 509 unvaccinated HZ patients. ZVL was associated with significantly lower risks of HZ-related pain at all time-points. The risk of PHN in vaccinated and unvaccinated patients, respectively, was 9.2% and 15.4% (aRR = 0.594, 95% CI: 0.413, 0.854); 2.0% and 4.8% of these patients reported pain ≥7 (aRR = 0.332, 95% CI: 0.153, 0.721). Irrespective of vaccination, the risk of PHN was lower in adults aged <70 years versus those ≥70 years and was similar or lower in females versus males. ConclusionWe used laboratory confirmation of HZ cases and patient survey to show that aside from preventing HZ, ZVL reduced HZ-related pain and prevented PHN among vaccine recipients who experienced HZ. Observational studies will be needed to evaluate long-term effectiveness of the new recombinant zoster vaccine and its benefits in protecting patients against PHN.

Recombinant Zoster Vaccine (Shingrix®): A Review in Herpes Zoster.

Shingrix® is a recombinant zoster vaccine (RZV) that contains a varicella zoster virus glycoprotein E antigen and the AS01B adjuvant system. The subunit vaccine is approved for the prevention of herpes zoster (HZ) [EU, USA, Japan, Canada and Australia] and postherpetic neuralgia (PHN) [EU and Australia] in adults aged ≥ 50years. In the pivotal trials in adults aged ≥ 50years (ZOE-50) and ≥ 70years (ZOE-70), RZV significantly reduced the risk of HZ and PHN. Its protective efficacy waned minimally over 4years and was well preserved in adults aged ≥ 70years. In patients with breakthrough disease, RZV reduced HZ-related pain severity, burden of illness and burden of interference with activities of daily living. RZV was more reactogenic than placebo, with injection-site reactions, myalgia and fatigue being the most common solicited adverse reactions. However, most solicited adverse reactions were transient and were mild to moderate in severity. RZV represents a novel, highly effective and well-tolerated vaccine option for HZ and PHN in adults aged ≥ 50years. RZV is not contraindicated in immunocompromised individuals, and is preferred over a live attenuated HZ vaccine in immunocompetent individuals, according to the US and Canadian guidelines.

Is herpes zoster an additional complication in old age alongside comorbidity and multiple medications? Results of the post hoc analysis of the 12-month longitudinal prospective observational ARIZONA cohort study

ObjectivesTo examine the burden of comorbidity, polypharmacy and herpes zoster (HZ), an infectious disease, and its main complication post-herpetic neuralgia (PHN) in young (50–70 years of age: 70−) and old...

Zoster Vaccine and the Risk of Postherpetic Neuralgia in Patients Who Developed Herpes Zoster Despite Having Received the Zoster Vaccine.

Although it is evident that zoster vaccination reduces postherpetic neuralgia (PHN) risk by reducing herpes zoster (HZ) occurrence, it is less clear whether the vaccine protects against PHN among patients who develop HZ despite previous vaccination. This cohort study included immunocompetent patients with HZ. The vaccinated cohort included 1155 individuals who were vaccinated against HZ at age ≥60 years and had an HZ episode after vaccination. Vaccinated patients were matched 1:1 by sex and age with unvaccinated patients. Trained medical residents reviewed the full medical record to determine the presence of HZ-related pain at 1, 2, 3, and 6 months after HZ diagnosis. The incidence of PHN was compared between vaccinated and unvaccinated -patients. Thirty vaccinated women (4.2%) experienced PHN, compared with 75 unvaccinated women (10.4%), with an adjusted relative risk of 0.41 (95% confidence interval, .26-.64). PHN occurred in 26 vaccinated men (6.0%) versus 25 unvaccinated men (5.8%), with an adjusted relative risk of 1.06 (.58-1.94). These associations did not differ significantly by age. Among persons experiencing HZ, prior HZ vaccination is associated with a lower risk of PHN in women but not in men. This sex-related difference may reflect differences in healthcare-seeking patterns and deserve further investigation.

Do Interventional Pain Management Procedures during the Acute Phase of Herpes Zoster Prevent Postherpetic Neuralgia in the Elderly?: A Meta-Analysis of Randomized Controlled Trials.

Do Interventional Pain Management Procedures during the Acute Phase of Herpes Zoster Prevent Postherpetic Neuralgia in the Elderly?: A Meta-Analysis of Randomized Controlled Trials.

ARIZONA study: is the risk of post-herpetic neuralgia and its burden increased in the most elderly patients?

BackgroundIn a context of change in the demographic profile of the older population, to identify an age threshold for increased risk and burden of herpes zoster (HZ) in 70+ patients.MethodsPost hoc analysis of the 12-month French nationwide prospective observational ARIZONA cohort study. HZ was assessed by means of the following validated questionnaires: Neuropathic Pain Symptom Inventory (NPSI), Zoster Brief Pain Inventory (ZBPI), Short-Form health survey (SF-12), and Hospital Anxiety and Depression Scale (HADS).Results644 general practitioners included 1,358 volunteer patients with acute HZ in the ARIZONA study; 609 patients (45%) were 70+. In 70+ patients, age did not increase rash severity or HZ-related pain intensity at diagnosis, but increased by 64% the frequency of ophthalmic zoster (from 5.5% in 70–74 years age-group to 9.0% in 85+ patients, p = NS). Age was significantly associated with low physical health as assessed by the SF-12 Physical Component Summary (SF-12 PCS) score and bad mood as assessed by the HADS depression score (p < 0.001). Within the year following HZ, post-herpetic neuralgia (PHN) was systematically but not significantly more frequent in 85+ patients than in the 70–74, 75–79, or 80–84 years age-groups (19.0% vs. 13.3%/15.3%/11.6% at month 3; 15.1% vs. 7.3%/11.0%/12.2% at month 6; 15.2% vs. 6.0%/8.0%/6.0% at month12, respectively). SF-12 PCS and HADS depression scores improved from day 0 to month 12 in all patients (p < 0.001). 85+ patients were more impaired than younger patients (p < 0.001), but without clear difference according to PHN.ConclusionsThis study did not show in 70+ patients a clear and significant age threshold at which disease burden increased, although for some domains the impact seemed higher among the oldest patients; the cut-off of 70 years remains thus relevant for clinical and epidemiological studies. However, at individual level, assessment of the burden of HZ and HZ-related pain appears necessary to improve management and prevent functional decline in the most vulnerable 70+ patients.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2334-14-529) contains supplementary material, which is available to authorized users.

Early antiviral treatment fails to completely prevent herpes-related pain

ObjectivesAntiviral therapy does not completely relieve herpes zoster (HZ)-related pain, including post-herpetic neuralgia (PHN). The 12-month longitudinal prospective observational ARIZONA study was conducted in primary care in France between November 20, 2006 and September 12, 2008. The ARIZONA study included data from 1358 patients 50 years of age or more, presenting with acute eruptive HZ. This article focuses on the relationship between antiviral therapy and HZ-related pain in this large population. Patients and methodsSix hundred and forty-four family physicians (FPs) consecutively included all patients 50years of age or more presenting with acute HZ in the eruptive phase. The FP documented every patient's demographic and medical characteristics, HZ characteristics, and prescribed drugs at inclusion, and the presence of HZ-related pain on day 15 and at months 1, 3, 6, 9, and 12. ResultsOne thousand two hundred and fifty-eight (92.6%) of the 1358 included patients (mean 67.7years [SD 10.7]; 62.2% female patients) were given antiviral drugs. The prevalence of HZ-related pain was 43.6%, 27.0%, 11.7%, 8.7%, 7.4%, and 6.0%, on day 15 and at months 1, 3, 6, 9, and 12, respectively. HZ-related pain was at least as frequent in patients treated by antiviral therapy within 72hours following HZ-rash onset as in patients treated later or who did not receive antiviral treatment, and more frequent in patients whose diagnosis was made within 24hours following HZ-rash onset. ConclusionsAntiviral therapy, even early, does not prevent HZ-related pain and PHN, probably because patients quickly identified and treated were those with severe forms and potentially at high risk of pain. Preventive strategies are thus needed.

Predictors of pain intensity and persistence in a prospective Italian cohort of patients with herpes zoster: relevance of smoking, trauma and antiviral therapy

BackgroundHerpes zoster (HZ) is a common disease, characterized by rash-associated localized pain. Its main complication, post-herpetic neuralgia (PHN), is difficult to treat and may last for months to years in the wake of rash resolution. Uncertainties remain as to the knowledge of predictors of HZ-related pain, including the role of antiviral therapy in preventing PHN in ordinary clinical practice. This prospective cohort study was aimed at investigating pain intensity at HZ presentation and its correlates, as well as the incidence of PHN and its predictors.MethodsPatients diagnosed with HZ were consecutively enrolled by a network of Italian General Practitioners and Hospital Units in the health district of Pescara, Italy, over two years. Uncertain cases were referred for microbiological investigation. Data were collected through electronic case report form (e-CRFs) at enrolment and at 1, 3, 6 and 12 months after enrolment. Pain intensity was coded on a five-degree semi-quantitative scale at each time point. PHN was defined as pain of any intensity during follow-up and quantified using an area-under-the-curve (AUC) method.ResultsFour hundred and forty-one patients composed the final sample. Mean age was 58.1 years (SD = 20.4 years); 43.5% of patients were males; 7.9% did not receive prescription of antivirals. Intense/very intense pain at presentation was reported by 25.2% of patients and was significantly associated with female gender, older age, cigarette smoking, trauma and/or surgery at HZ site (logistic regression). PHN was diagnosed in 51.2% of patients at one month and in 30.0% of patients at three months. PHN was significantly associated with pain intensity at presentation, age, smoking, trauma and missed antiviral prescription (generalized estimating equations model). The same factors were also independent predictors of the overall pain burden as described by the AUC method (linear regression).ConclusionsSmoking, traumas and surgery at the HZ site emerged as new predictors of both HZ-related pain intensity and persistence, opening new perspectives in the prevention of HZ-related pain. An independent line of evidence was provided for the efficacy of antiviral therapy in preventing PHN and reducing total pain burden.

The impact of herpes zoster and subsequent chronic pain on patients’ daily lives

AimThe aim of our study was to carry out a literature review and develop a model illustrating the domains of patients’ lives that are impacted by herpes zoster (HZ) and subsequent chronic pain.Subjects and methodsBiomedical databases and online congress archives were searched using keywords related to HZ or post-herpetic neuralgia (PHN) and social, psychological or physical impact. A total of 733 abstracts were reviewed, and 29 publications containing concepts reported by patients were retained for the model. Wilson and Cleary’s model was used to organise the findings. Links between concepts were documented on three levels: hypothesis, observation and evidence. The final model illustrates the concepts impacted by HZ and PHN, relationships between these concepts and the level of evidence identified.ResultsThe concepts identified from the articles were grouped into the following categories: biological/physiological, symptom status, functional status, health perceptions, characteristics of the individual, health-related quality of life (HRQOL), treatment and characteristics of the environment. Evidence exists showing that HZ-related pain directly impacts functional status, health perceptions and HRQOL.ConclusionPatients report that all major domains of life are impaired by HZ or subsequent chronic pain. HZ and its painful and debilitating complications can have a substantial impact on physical, psychological, social and role functioning, HRQOL and activities of daily living. The impact on elderly patients needs to be further assessed with appropriately designed and validated instruments, with specific attention paid to dependence.

Design issues for studies into prevention of chronic pain: lessons from post-herpetic neuralgia.

Design issues for studies into prevention of chronic pain: lessons from post-herpetic neuralgia.

The PINE study: rationale and design of a randomised comparison of epidural injection of local anaesthetics and steroids versus care-as-usual to prevent postherpetic neuralgia in the elderly [ISRCTN32866390

BackgroundPostherpetic neuralgia (PHN) is by far the most common complication of herpes zoster (HZ) and one of the most intractable pain disorders. Since PHN is seen most often in the elderly, the number of patients with this disorder is expected to increase in our ageing society. PHN may last for months to years and has a high impact on the quality of life. The results of PHN treatment are rather disappointing. Epidural injection of local anaesthetics and steroids in the acute phase of HZ is a promising therapy for the prevention of PHN. Since randomised trials on the effectiveness of this intervention are lacking, the PINE (Prevention by epidural Injection of postherpetic Neuralgia in the Elderly) study was set up. The PINE study compares the effectiveness and cost-effectiveness of a single epidural injection of local anaesthetics and steroids during the acute phase of HZ with that of care-as-usual (i.e. antivirals and analgesics) in preventing PHN in elderly patients.Methods / designThe PINE study is an open, multicenter clinical trial in which 550 elderly (age ≥ 50 yr.) patients who consult their general practitioner in the acute phase of HZ (rash < 7 days) are randomised to one of the treatment groups. The primary clinical endpoint is the presence of HZ-related pain one month after the onset of the rash. Secondary endpoints include duration and severity of pain, re-interventions aiming to treat the existing pain, side effects, quality of life, and cost-effectiveness.ConclusionThe PINE study is aimed to quantify the (cost-) effectiveness of a single epidural injection during the acute phase of HZ on the prevention of PHN.