Neurological Manifestations of Varicella Zoster Medication

  • Author: Wayne E Anderson, DO; Chief Editor: Karen L Roos, MD   more...
 
Updated: May 11, 2011
 

Medication Summary

The decision to select a specific medication must be a clinical decision. This guide cannot substitute for medical decision making.

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Antiviral agents

Class Summary

These may help reduce pain, symptoms, and incidence of PHN. All 3 medications must be used cautiously in cases of renal compromise. Hemolytic uremic syndrome is rare but reported. All 3 agents may be used for 7-10 days, depending on response. Only acyclovir is available in IV form.

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Acyclovir (Zovirax)

 

Prodrug activated by phosphorylation by virus-specific thymidine kinase that inhibits viral replication. Herpes virus thymidine kinase, but not host cells thymidine kinase, uses acyclovir as a purine nucleoside, converting it into acyclovir monophosphate, a nucleotide analogue. Guanylate kinase converts the monophosphate form into diphosphate and triphosphate analogues that inhibit viral DNA replication.

Has affinity for viral thymidine kinase and once phosphorylated causes DNA chain termination when acted on by DNA polymerase. Inhibits activity of both HSV-1 and HSV-2. Patients experience less pain and faster resolution of cutaneous lesions when used within 48 h from rash onset. May prevent recurrent outbreaks. Early initiation of therapy is imperative.

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Valacyclovir (Valtrex)

 

Prodrug that is converted rapidly to acyclovir before exerting antiviral activity.

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Famciclovir (Famvir)

 

After ingestion, drug is rapidly biotransformed into active compound penciclovir and phosphorylated by viral thymidine kinase. By competition with deoxyguanosine triphosphate, penciclovir triphosphate inhibits viral polymerase subsequently inhibiting viral DNA synthesis/replication.

Adjust dose in patients with renal insufficiency or hepatic disease.

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Corticosteroids

Class Summary

Some authors find benefit in the short-term use of steroids. Some evidence exists to suggest a decreased incidence of PHN in patients who received steroids. Other studies find no benefit from the use of steroids. This author does not begin steroids in typical zoster cases.

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Prednisone (Sterapred)

 

Steroid use is controversial, but remains one therapeutic option. Prednisone is inactive and must be metabolized to active metabolite prednisolone. Conversion may be impaired in patients with liver disease.

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Vaccines

Class Summary

Elicit active immunization to increase resistance to infection. Vaccines consist of attenuated microorganisms or cellular components, which act as antigens. Administration stimulates antibody production with specific protective properties.

In March 2011, the Food and Drug Administration (FDA) lowered the approved age for use of Zostavax to 50-59 years. Zostavax was already approved for use in individuals aged 60 years or older. Annually, in the United States, shingles affects approximately 200,000 healthy people aged 50-59 years. Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST).[11] The trial was conducted in the United States and 4 other countries in 22,439 people aged 50-59 years. Participants were randomized in a 1:1 ratio to receive either Zostavax or placebo. Participants were monitored for at least 1 year to see if shingles developed. Compared with placebo, Zostavax significantly reduced the risk of developing zoster by approximately 70%.

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Varicella zoster vaccine (Zostavax)

 

This is a lyophilized preparation of the Oka/Merck strain of live, attenuated varicella-zoster virus (VZV). It has been shown to boost immunity against herpes zoster virus (shingles) in older patients. It reduces the occurrence of shingles in individuals older than 60 years by about 50%. For individuals aged 60-69 years, it reduces the occurrence by 64%. In the ZEST trial, the vaccine significantly reduced the risk by 70% in subjects aged 50-59 years. It also slightly reduces pain compared with no vaccination in those who develop shingles. It is indicated for the prevention of herpes zoster in patients who have no contraindications.

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Analgesics

Class Summary

Topical analgesics that contain capsaicin have been shown to be effective for temporary relief of neuropathic pain.

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Capsaicin transdermal patch (Qutenza)

 

Transient receptor potential vanilloid-1 (TRPV1) agonist indicated for neuropathic pain associated with postherpetic neuralgia. TRPV1 is an ion channel–receptor complex expressed on nociceptive skin nerve fibers. Topical capsaicin causes initial TRPV1 stimulation that may cause pain, followed by pain relief by reduction in TRPV1-expressing nociceptive nerve endings. Neuropathic pain may gradually recur over several months (thought to be caused by TRPV1 nerve fiber reinnervation of treated area).

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Contributor Information and Disclosures
Author

Wayne E Anderson, DO  Assistant Professor of Internal Medicine/Neurology, College of Osteopathic Medicine of the Pacific Western University of Health Sciences; Clinical Faculty in Family Medicine, Touro University College of Osteopathic Medicine; Clinical Instructor, Departments of Neurology and Pain Management, California Pacific Medical Center

Wayne E Anderson, DO is a member of the following medical societies: American Academy of Neurology, American Medical Association, American Society of Law, Medicine & Ethics, California Medical Association, and San Francisco Medical Society

Disclosure: Cephalon Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; King Honoraria Speaking and teaching; Forest Honoraria Speaking and teaching

Specialty Editor Board

J Stephen Huff, MD  Associate Professor of Emergency Medicine and Neurology, Department of Emergency Medicine, University of Virginia School of Medicine

J Stephen Huff, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Florian P Thomas, MD, MA, PhD, Drmed  Director, Spinal Cord Injury Unit, St Louis Veterans Affairs Medical Center; Director, National MS Society Multiple Sclerosis Center; Director, Neuropathy Association Center of Excellence, Professor, Department of Neurology and Psychiatry, Associate Professor, Institute for Molecular Virology, and Department of Molecular Microbiology and Immunology, St Louis University School of Medicine

Florian P Thomas, MD, MA, PhD, Drmed is a member of the following medical societies: American Academy of Neurology, American Neurological Association, American Paraplegia Society, Consortium of Multiple Sclerosis Centers, and National Multiple Sclerosis Society

Disclosure: Nothing to disclose.

Chief Editor

Karen L Roos, MD  John and Nancy Nelson Professor of Neurology, Professor of Neurological Surgery, Department of Neurology, Indiana University School of Medicine

Karen L Roos, MD is a member of the following medical societies: American Academy of Neurology and American Neurological Association

Disclosure: Nothing to disclose.

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Herpes zoster in the ophthalmic (V1) distribution of the trigeminal nerve. Note the unilateral distribution of the rash and how the V1 distribution may extend to the tip of the nose. Though at risk for keratitis with zoster in this distribution, the patient had a normal ocular examination. Patient consented to picture distribution for educational use; written permission on file; contributed by JS Huff.
 
 
 
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