Varicella-Zoster (Shingles) Organism-Specific Therapy 

Updated: Feb 12, 2018
  • Author: Richard Lichenstein, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Organism-Specific Therapy

The Centers for Disease Control and Prevention (CDC) estimate that one-third of people in the United States will develop shingles, also known as herpes zoster, in their lifetime. There are an estimated 1 million cases of shingles each year in the United States. The risk for herpes zoster increases sharply after age 50 years. [1]

Herpes varicella zoster therapeutic regimens are provided below, including those for antivirals and zoster vaccines.

Treatment

Therapy should be initiated at the earliest sign or symptom of herpes zoster and is most effective when started generally within 72h of the onset of zoster rash.

Zoster confined to dermatome (normal or immunocompromised patients):

Visceral, central nervous system, or disseminated VZV infections, and zoster in severely immunocompromised patients:

  • Acyclovir 10 mg/kg (500 mg/m 2 in children <12 y) IV q8h for 7-10d

Prevention

Despite longstanding recommendations for use of many vaccines, vaccination coverage among US adults is low. In 2015, among adults aged 60 years or older, 30.6% reported receiving herpes zoster vaccination to prevent shingles, a 2.7% increase from 2014. Whites aged 65 years or older had higher herpes zoster vaccination coverage (38.3%) compared with blacks (14.1%), Hispanics (19.2%), and Asians (30.6%). [4]

The immunization recommendations from the CDC include the following: [2, 7]

  • Administer two doses of recombinant zoster vaccine (RZV) (Shingrix) 2-6 months apart to adults aged 50 years or older, regardless of past episode of herpes zoster or receipt of zoster vaccine live (ZVL) (Zostavax).
  • Administer two doses of RZV 2-6 months apart to adults who previously received ZVL at least 2 months after ZVL.
  • For adults aged 60 years or older, administer either RZV or ZVL (RZV is preferred).

Zoster vaccine recombinant, adjuvanted (Shingrix)

  • Used for the prevention of herpes zoster (shingles) in patients aged 50 years or older; not used for the treatment of herpes zoster
  • Used in immunocompetent adults who previously received Zostavax
  • ACIP recommends new two-dose (Shingrix) preferentially over older one-dose (Zostavax)
  • Administer 0.5 mL (entire vial contents) IM in the deltoid region, 2-6 months apart

Approval was based on a multicenter trial, Zoster Efficacy Study in Adults 50 Years of Age or Older (ZOE-50). The trial was conducted in 18 countries in 13,900 people aged 70 years or older. Participants were randomized in a 1:1 ratio to receive either Shingrix or placebo. Mean follow-up period was 3.7 years. The efficacy for the prevention of herpes zoster was 96.6% in persons aged 50-59 years, 97.4% in persons aged 60-69 years, and 91.3% in persons aged 70 years or older. [5, 6]

Zoster vaccine live (Zostavax)

  • Used for the prevention of herpes zoster (shingles) in patients ≥60 years (ACIP guidelines); not used for the treatment of herpes zoster
  • Administer 0.65 mL (entire vial contents) SC in the deltoid region of the upper arm

Note: In March 2011, the Food and Drug Administration (FDA) lowered the approved age for use of Zostavax to 50-59y. Zostavax was already approved for use in individuals aged 60 years or older. [3]

Approval was based on a multicenter study, the Zostavax Efficacy and Safety Trial (ZEST). [3] The trial was conducted in the United States and 4 other countries in 22,439 people aged 50-59y. Participants were randomized in a 1:1 ratio to receive either Zostavax or placebo. Participants were monitored for at least 1y to see if shingles developed. Compared with placebo, Zostavax significantly reduced the risk of developing zoster by approximately 70%.