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Antiviral Therapy of Acute Herpes Zoster in Older Patients

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  • Drug Therapy
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Summary

Although herpes zoster (shingles) can occur in anyone with a history of chickenpox, it is more prevalent and usually more severe in older patients (i.e. persons over 50 years of age). While the cutaneous manifestations of shingles usually resolve in approximately 4 weeks, the pain can persist for several months, or even years in the untreated patient. This pain following healing of the skin, termed post-herpetic neuralgia (PHN), can be very severe.

Three well tolerated and effective antiviral drugs are available for the therapy of acute herpes zoster. The nucleoside analogues, aciclovir, famciclovir and valaciclovir, appear to shorten the duration of PHN to a similar degree, but none affects the incidence of PHN. Aciclovir is taken 5 times daily for 7 days, while famciclovir is taken 3 times daily for 7 days. Valaciclovir, the L-valyl ester of aciclovir, when taken orally, produces plasma levels of aciclovir equivalent to those seen following intravenous administration of aciclovir. Valaciclovir has not only been proved to be more efficient than aciclovir (i.e. 3 times daily administration) but also more effective than aciclovir in shortening the duration of PHN. Current studies are determining the relative efficacy of valaciclovir versus famciclovir.

Presently, a fourth drug, sorivudine, is being compared with aciclovir for the therapy of acute herpes zoster in older patients, but data from these trials are not yet available.

Corticosteroids have been used to treat herpes zoster for much longer than the antiviral drugs, but the effect of corticosteroids on PHN does not appear to be consistent. Corticosteroids plus aciclovir did not provide an added benefit over aciclovir alone in one study but this combination did appear to improve the quality of life of older patients in another investigation.

The recent availability of the varicella zoster vaccine may cause shingles to be an uncommon and/or mild disease by the mid twenty-first century. Meanwhile, the search continues for more effective and efficient therapies for acute herpes zoster with the primary goal in older patients to affect the most important sequela of zoster in this population, PHN.

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References

  1. Burgoon CF, Burgoon JS, Baldridge GD. The natural history of herpes zoster. JAMA 1957; 164: 265–9

    Article  Google Scholar 

  2. Hope-Simpson RE. The nature of herpes zoster — a long-term study and a new hypothesis. Proc R Soc Lond B 1965; 58: 9–20

    CAS  Google Scholar 

  3. Ragozzino MW, Melton LF, Kurland LT. Population-based study of herpes zoster and its sequelae. Medicine 1982; 61: 310–6

    Article  PubMed  CAS  Google Scholar 

  4. Ostrove JM, Inchauspe G. Varicella-zoster virus infections: biology, natural history treatment and prevention. Ann Intern Med 1988; 108(2): 221–37

    PubMed  Google Scholar 

  5. Dolin R, Reichman RC, Mazur MH, et al. Herpes zoster varicella infections in immunosuppressed patients. Ann Intern Med 1978; 89: 375–88

    PubMed  CAS  Google Scholar 

  6. Gnann JW, Whitley RJ. Natural history and treatment of varicella-zoster in high-risk populations. J Hosp Infect 1991; 18 Suppl. A: 317–29

    Article  PubMed  Google Scholar 

  7. Rogers RS, Tindall JP. Geriatric herpes zoster. J Am Geriatr Soc 1971; 19(6): 495–503

    PubMed  Google Scholar 

  8. Gilden DM, Dueland AN, Cohrs R, et al. Preherpetic neuralgia. Neurology 1991; 41: 1215–8

    Article  PubMed  CAS  Google Scholar 

  9. Lewis GW. Zoster sine herpete. BMJ 1958; 2: 418–21

    Article  PubMed  CAS  Google Scholar 

  10. Portenoy RK, Duma C, Foley KM. Acute herpetic and post-herpetic neuralgia: clinical review and current management. Ann Neurol 1986; 20: 651–64

    Article  PubMed  CAS  Google Scholar 

  11. de Moragas JM, Kierland RR. The outcome of patients with herpes zoster. Arch Dermatol 1957; 75: 193–6

    Article  Google Scholar 

  12. Culbertson WW, Blumenkranz MS, Pepose JS, et al. Varicellazoster virus is a cause of the acute retinal necrosis syndrome. Ophthalmology 1986; 93: 559–62

    PubMed  CAS  Google Scholar 

  13. Tyring SK. The natural history of varicella zoster virus. Semin Dermatol 1992; 11(3): 211–7

    PubMed  CAS  Google Scholar 

  14. Mazur MH, Dolin R. Herpes zoster at the NIH: a twenty-year history. Am J Med 1978; 65: 738–44

    Article  PubMed  CAS  Google Scholar 

  15. Merselis JG, Kaye D, Hook EW. Disseminated herpes zoster. Arch Intern Med 1964; 113: 679–86

    Article  PubMed  Google Scholar 

  16. Wood MJ. Current experience with antiviral therapy for acute herpes zoster. Ann Neurol 1994; 35: 565–8

    Article  Google Scholar 

  17. Strommen GL, Pucino F, Tight RR, et al. Human infection with herpes zoster: etiology, pathophysiology, diagnosis, clinical course, and treatment. Pharmocotherapy 1988; 8(1): 52–68

    CAS  Google Scholar 

  18. Juel-Jensen BE, MacCallum FO, MacKenzie AMR, et al. Treatment of zoster with idoxuridine dimethyl sulfoxide: results of two double-blind controlled trials. BMJ 1970; 4: 776–80

    Article  PubMed  CAS  Google Scholar 

  19. Dawber R. Idoxuridine in the treatment of herpes zoster: further evaluation of intermittent topical therapy. BMJ 1974; 2: 526–7

    Article  PubMed  CAS  Google Scholar 

  20. Wildenhoff KE, Insen J, Esmann V, et al. Treatment of herpes zoster with idoxuridine ointment including a multivariate analysis of signs and symptoms. Scand J Infect Dis 1979; 11: 1–9

    PubMed  CAS  Google Scholar 

  21. Wildenhoff KE, Esmann V, Ipsen J, et al. Treatment of trigeminal and thoracic zoster with idoxuridine. Scan J Infect Dis 1981; 13: 257–62

    CAS  Google Scholar 

  22. Loeser JD. Herpes zoster and post herpetic neuralgia. Pain 1986; 25: 149–64

    Article  PubMed  CAS  Google Scholar 

  23. Zaky A, Betts RF, Douglas RG, et al. Double-blind study of cytarabine in localized herpes zoster [abstract]. Clin Res 1974; 22: 458A

    Google Scholar 

  24. Stevens DA, Jordan GW, Waddel TF, et al. Adverse effects of cytosine arabinoside on disseminated herpes zoster in a controlled trial. N Engl J Med 173; 289: 873-977

  25. Betts RF, Zaky DA, Douglas Jr RG, et al. Ineffectiveness of subcutaneous cytosine arabinoside in localized herpes zoster. Ann Intern Med 1975; 82: 778–83

    PubMed  CAS  Google Scholar 

  26. Sasadeusz JJ, Sachs SL. Systemic antivirals in herpesvirus infections. Dermatol Ther 1993; 11(1): 171–85

    CAS  Google Scholar 

  27. Whitley RJ, Chien LT, Dolin R, et al. Adenine arabinoside therapy of herpes zoster in the immunosuppressed. N Engl J Med 1976; 294: 1193–9

    Article  PubMed  CAS  Google Scholar 

  28. Whitley RJ, Soong ST, Dolin R, et al. Early vidarabine therapy to control the complications of herpes zoster in immunosuppressed patients. N Engl J Med 1982; 307(16): 971–5

    Article  PubMed  CAS  Google Scholar 

  29. Shepp DH, Dandicker PS, Meyers JD. Treatment of varicellazoster virus infection in severely immunocompromised patients: a randomized comparison of aciclovir and vidarabine. N Engl J Med 1986; 314(4): 208–12

    Article  PubMed  CAS  Google Scholar 

  30. Vilde JL, Bricaire F, Leport C, et al. Comparative trial of acyclovir and vidarabine in disseminated varicella-zoster virus infections in immunosuppressed patients. J Med Virol 1986; 20: 127–34

    Article  PubMed  CAS  Google Scholar 

  31. Whitley RJ, Gnann JW, Hinthorn D, et al. Disseminated herpes zoster in the immunocompromised host: a comparative trial of acyclovir and vidarabine. J Infect Dis 1992; 165: 450–5

    Article  PubMed  CAS  Google Scholar 

  32. Elion GB, Furman PA, Fyfe JH, et al. Selectivity of action of an antiherpetic agent, 9-[ (2-hydroxyethoxy)methyl] guanine. Proc Natl Acad Sci USA 1977; 74(4): 5716–20

    Article  PubMed  CAS  Google Scholar 

  33. Derse D, Cheng Y-C, Furman PA, et al. Inhibition of purified human and herpes simplex virus-induced DNA polymerases by 9- (2-hydroxyethoxymethyl) guanine triphosphate. J Biol Chem 1981; 256(11): 11447–51

    PubMed  CAS  Google Scholar 

  34. McGuirt PV, Furman PA. Acyclovir inhibition of DNA chain elongation in herpes simplex virus-infected cells. Am J Med 1982; 73 Suppl.: 67–71

    Article  PubMed  CAS  Google Scholar 

  35. Straus SE. Shingles: sorrows, salves, and solutions. JAMA 1994; 269(14): 1836–9

    Article  Google Scholar 

  36. Cirelli R, Memar O, Herne K, et al. Therapy and prophylaxis of viral diseases with cutaneous manifestations. Can J Dermatol 1995; 7: 795–804

    Google Scholar 

  37. Purifoy DJM, Beauchamp LU, de Miranda P, et al. Review of research leading to new anti-herpes virus agents in clinical development: valacyclovir hydrochloride (256U, the L-valyl ester of acyclovir) and 882C, a specific agent for varicella zoster virus. J Med Virol 1993; Suppl. 1: 139–45

    Article  PubMed  Google Scholar 

  38. Gelb LD. Varicella zoster virus infections. Current Opin Infect Dis 1989; 2: 256–61

    Article  Google Scholar 

  39. Serupere A, Sauz GF, Sevant L, et al. Long-term acyclovir prophylaxis for prevention of varicella zoster virus infection after autologous blood stem cell transplantation in patients with acute leukemia. Bone Marrow Transplant 1992; 10: 495–8

    Google Scholar 

  40. Goldberg LH, Kaufman R, Kurtz TO, et al. for the Acyclovir Study Group. Long-term suppression of recurrent genital herpes with acyclovir: a 5-year benchmark. Arch Dermatol 1993; 129: 582–7

    Article  PubMed  CAS  Google Scholar 

  41. Peterslund NA, Seyer-Hausen K, Ipsen J, et al. Acyclovir in herpes zoster. Lancet 1981; ii: 827–30

    Article  Google Scholar 

  42. Bean B, Braun C, Balfour Jr HH. Acyclovir therapy for acute herpes zoster. Lancet 1982; ii: 118–21

    Article  Google Scholar 

  43. van den Broek PJ, van der Meer JWM, Mulder JD, et al. Limited value of acyclovir in the treatment of uncomplicated herpes zoster: a placebo-controlled study. Infection 1984; 12: 338–41

    Article  PubMed  Google Scholar 

  44. Juel-Jensen BF, Khan JA, Pasvol G. High dose intravenous acyclovir in the treatment of zoster: a double-blind placebo-controlled trial. J Infect 1983; 6 Suppl. I: 31–6

    Article  PubMed  CAS  Google Scholar 

  45. McGill J, McDonald DR, Fall C, et al. Intravenous acyclovir in acute herpes zoster infection. J Infect 1983; 6: 157–61

    Article  PubMed  CAS  Google Scholar 

  46. Balfour Jr HH, Bean B, Laskin OL, et al. Acyclovir halts progression of herpes zoster in immunocompromised patients. N Engl J Med 1983; 308: 1448–53

    Article  PubMed  Google Scholar 

  47. Peterslund NA, Esmann J, Ipsen K, et al. Oral and intravenous acyclovir are equally effective in herpes zoster. J Antimicrob Chemother 1985; 14: 185–9

    Article  Google Scholar 

  48. McKendrick MW, Care C, Burke C, et al. Oral acyclovir in herpes zoster. J Antimicrob Chemother 1984; 15: 661–5

    Article  Google Scholar 

  49. Wassilew SW, Reimlinger S, Nasemann T, et al. Oral acyclovir for herpes zoster: a double-blind controlled trial in normal subjects. Br J Dermatol 1987; 117: 495–501

    Article  PubMed  CAS  Google Scholar 

  50. Cobo LM, Foulks GN, Liesegang T, et al. Oral acyclovir in the treatment of acute herpes zoster ophthalmicus. Ophthalmology 1986; 93: 763–70

    PubMed  CAS  Google Scholar 

  51. Huff JC, Bean B, Balfour Jr HH, et al. Therapy of herpes zoster with oral acyclovir. Am J Med 1988; 85 Suppl. 2A: 84–9

    PubMed  CAS  Google Scholar 

  52. Wood MJ, Ogan PH, McKendrick MW, et al. Efficacy of oral acyclovir in the treatment of acute herpes zoster. Am J Med 1989; 85 Suppl. 2A: 79–83

    Google Scholar 

  53. Morton P, Thomson AN. Oral acyclovir in the treatment of herpes zoster in general practice. N Z Med J 1989; 102: 93–5

    PubMed  CAS  Google Scholar 

  54. Harding SP, Porter SM. Oral acyclovir in herpes zoster ophthalmicus. Curr Eye Res 1991; 10: 177–82

    Article  PubMed  Google Scholar 

  55. Huff JC, Drucker JL, Clemmer A, et al. Efficacy of oral acyclovir on pain resolution in herpes zoster: a reanalysis. J Med Virol 1993; Suppl. 1: 93–6

    Article  PubMed  Google Scholar 

  56. Crooks RT, Jones DA, Fiddian AP. Zoster-associated chronic pain: an overview of clinical trials with acyclovir. Scand J Infect 1991; Suppl. 78: 62–8

    Google Scholar 

  57. Wood MJ, Johnson RW, McKendrick MW, et al. A randomized trial of acyclovir for 7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med 1994; 330: 896–900

    Article  PubMed  CAS  Google Scholar 

  58. Elliott FA. Treatment of herpes zoster with high doses of prednisone. Lancet 1964; ii: 610–1

    Article  Google Scholar 

  59. Eaglstein WH, Katz R, Brown JA. The effects of early corticosteroid therapy on the skin eruption and pain of herpes zoster. JAMA 1970; 211(10): 1681–3

    Article  PubMed  CAS  Google Scholar 

  60. Keczkes K, Basheer AM. Do corticosteroids prevent post-herpetic neuralgia? Br J Dermatol 1989; 102: 551–5

    Article  Google Scholar 

  61. Clemmensen OJ, Anderson KE. ACTH versus prednisone and placebo in herpes zoster treatment. Clin Exp Dermatol 1984; 9: 557–63

    Article  PubMed  CAS  Google Scholar 

  62. Esmann V, Geil JP, Kroon S, et al. Prednisolone does not prevent post herpetic neuralgia. Lancet 1987; ii: 126–9

    Article  Google Scholar 

  63. Post B, Philbrick JT. Do corticosteroids prevent postherpetic neuralgia? A review of the evidence. J Am Acad Dermatol 1988; 18: 605–10

    Article  PubMed  CAS  Google Scholar 

  64. Merselis JG, Kaye D, Hook EW. Disseminated herpes zoster. Arch Intern Med 1964; 113: 679–86

    Article  PubMed  Google Scholar 

  65. Whitley RJ, Weiss H, Gnann J, et al. The efficacy of steroids and acyclovir therapy of herpes zoster in the elderly [abstract]. Antiviral Res 1995; 26: A303

    Article  Google Scholar 

  66. Bacon T. Famciclovir: potency, predictability, and persistence [abstract]. Third Congress of the European Academy of Dermatology and Venereology; 1993 Sep 26–30; Copenhagen, Denmark, 6-7

  67. Earnshaw DL, Vere Hodge RA. Effective inhibition of herpes-virus DNA synthesis by (S)-penciclovir-triphosphate [abstract 1707]. American Society for Microbiology, 32nd Interscience Conference on Antimicrobial Agents and Chemotherapy. 1992 Oct 11–14; Anaheim

  68. Pratt SK, Beerahee M, Pere MA, et al. The pharmacokinetics of penciclovir following oral administration of 500mg famciclovir to patients with uncomplicated herpes zoster [poster]. Third Congress of the European Academy of Dermatology and Venereology; 1993 Sep 26–30; Copenhagen, Denmark, 18–9

  69. Vere Hodge RA. Famciclovir and penciclovir. The mode of action of famciclovir including its conversion to penciclovir. Antiviral Chem Chemother 1993; 4(2): 67–84

    CAS  Google Scholar 

  70. Boyd MR, Bacon TH, Sutton D, et al. Antiherpesvirus activity of 9- (4-hydroxy-3-hydroxymethylbut-1-yl) guanine (BRL 39123) in cell culture. Antimicrob Agents Chemother 1987; 31: 1238–42

    Article  PubMed  CAS  Google Scholar 

  71. Pue MA, Benet LZ. Pharmacokinetics of famciclovir in man. Antiviral Chem Chemother 1993; 4 Suppl. 1: 47–55

    CAS  Google Scholar 

  72. Pratt SK, Fairless AJ, Peu MA, et al. The haemodialysis of penciclovir [abstract 1286]. Sixth International Congress for Infectious Diseases; 1994 Apr 26–30; Prague, Czech Republic

  73. Saltzman R, Jurewicz R, Boon R. Safety of famciclovir in patients with herpes zoster and genital herpes. Antimicrob Agents Chemother 1994; 38(10): 2454–7

    Article  PubMed  CAS  Google Scholar 

  74. Tyring SK, Nahlik J, Cunningham A, et al. A double-blind, randomized, placebo-controlled, parallel group study of oral famciclovir for the treatment of uncomplicated herpes zoster. Ann Intern Med 1995; 123: 89–96

    PubMed  CAS  Google Scholar 

  75. Degreef H, Famciclovir Herpes Zoster Clinical Study Group. Famciclovir, a new oral antiherpes drug: results of the first controlled clinical study demonstrating its efficacy and safety in the treatment of uncomplicated herpes zoster in immuno-competent patients. Int J Antimicrob Agents 1994; 4: 241–6

    Article  PubMed  CAS  Google Scholar 

  76. Jacobson MA. Valacyclovir (BW256U87): the 1-valyl ester of acyclovir. J Med Virol 1993; Suppl. 1: 150–3

    Article  PubMed  Google Scholar 

  77. Burnette TC, de Miranda P. Metabolic disposition of the acyclovir prodrug valacyclovir in the rat. Drug Metab Dispos 1994; 22(1): 60–4

    PubMed  CAS  Google Scholar 

  78. de Miranda P, Burnette TC. Metabolic fate and pharmacokinetics of the acyclovir prodrug valacyclovir in cynomolgus monkeys. Drug Metab Dispos 1994; 22(1): 55–9

    PubMed  Google Scholar 

  79. Weiler S, Blum MR, Doucette M, et al. Pharmacokinetics of the acyclovir prodrug valacyclovir after escalating single- and multiple-dose administration to normal volunteers. Clin Pharmacol Ther 1993; 54(6): 595–605

    Article  Google Scholar 

  80. Feinberg J, Gallant J, Weiler S, et al. A phase I evaluation of 256U87, an acyclovir prodrug, in HIV infected patients [abstract No. POB3885]. Eighth International Conference on AIDS; 1992 Jul 19–24; Amsterdam

  81. Darby G. Acyclovir — and beyond. J Int Med Res 1994; 22 Suppl. 1: 33A–42A

    PubMed  Google Scholar 

  82. Beutner KR, Friedman DJ, Forszpaniak C, et al. Valacyclovir compared with acyclovir for improved therapy for herpes zoster in immunocompetent adults. Antimicrob Agents Chemother 1995; 39: 1546–53

    Article  PubMed  CAS  Google Scholar 

  83. Beutner K. Antivirals in the treatment of pain. J Geriatr Dermatol 1994; 2 Suppl. 6: 23A–8A

    Google Scholar 

  84. Gnann JW. New antivirals with activity against varicella-zoster virus. Ann Neurol 1994; 35 Suppl.: S69–72

    Article  PubMed  CAS  Google Scholar 

  85. Crooks RJ, Peck RW, Wood MJ. An open study to investigate the clinical potential, pharmacokinetics, and safety of 882C in patients with herpes zoster [abstract]. Antiviral Res 1993; 20 Suppl. 1: 144

    Google Scholar 

  86. Fiddian AP, and the International Zoster Study Group. A randomized controlled trial of Zovirax (acyclovir, ACV) versus netivudine for the treatment of herpes zoster [abstract]. Antiviral Res 1995; 26: A297

    Article  Google Scholar 

  87. Wallace MR, Sawyer MH, Chamberlin CK, et al. BV-ara-U for the treatment of adult varicella [abstract 25]. The Second International Conference on the Varicella Zoster Virus; 1994 Jul; Paris

  88. Boag F, Bodsworth N, Burdge D, et al. The safety and efficacy of sorivudine (BV-ara-u) for the treatment of zoster in HIV-infected adults: results of a multinational comparative trial [abstract 26]. The Second International Conference on the Varicella Zoster Virus; 1994 Jul; Paris

  89. Hardy I, Gershon AA, Steinberg SP, et al. The incidence of zoster after immunization with live attenuated varicella vaccine. N Engl J Med 1991; 325: 1545–50

    Article  PubMed  CAS  Google Scholar 

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  1. Department of Microbiology/Immunology and Internal Medicine, The University of Texas Medical Branch, Route 1019, Galveston, Texas, 77555, USA

    Kathleen Herne, Richard Cirelli & Patricia Lee

  2. Departments of Microbiology/Immunology, Internal Medicine and Dermatology, The University of Texas Medical Branch, Galveston, Texas, USA

    Stephen K. Tyring

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Herne, K., Cirelli, R., Lee, P. et al. Antiviral Therapy of Acute Herpes Zoster in Older Patients. Drugs & Aging 8, 97–112 (1996). https://doi.org/10.2165/00002512-199608020-00004

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