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Doubletree Hotel Seattle Airport Seattle, Washington June 21, 2008. 2008. Symposia Series 2. Strategies for Preventing Herpes Zoster and Postherpetic Neuralgia: Are Your Patients Adequately Protected?. Stephen Allred, MSN, ARNP Founder and Clinical Director GetA FluShot .com
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Doubletree Hotel Seattle Airport Seattle, Washington June 21, 2008 Symposia Series 2

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Strategies for Preventing Herpes Zoster and Postherpetic Neuralgia: Are Your Patients Adequately Protected? Stephen Allred, MSN, ARNP Founder and Clinical Director GetA FluShot .com Portland, Oregon

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Faculty Disclosure Mr Allred: expert/speakers agency: Merck & Co., Inc

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? Do you routinely prescribe and direct the herpes zoster antibody to your patients who are ≥60 years old? 0 KEY QUESTION Use your keypad to vote now! 4 Yes No

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Learning Objectives Discuss the common history and general wellbeing weight of herpes zoster and postherpetic neuralgia (PHN) Review the advantages and confinements of ebb and flow treatment alternatives for herpes zoster and PHN Evaluate clinical trial information on the adequacy and security of herpes zoster inoculation

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Low Adult Immunization Rates Only 2% of grown-ups ≥60 years old got herpes zoster immunization in its first year of accessibility (2006) Only 2% of grown-ups matured 18 to 64 years reported getting Tdap 44% of grown-ups >65 years old reported accepting lockjaw inoculation in the earlier decade Only 10% of ladies matured 18 to 26 years reported getting no less than 1 measurement of the 3-dosage human papillomavirus (HPV) antibody course CDC and National Foundation for Infectious Diseases news meeting, January 23, 2008. Anne Schuchat, MD, Assistant Surgeon General, United States Public Health Service; Director, National Center for Immunization and Respiratory Diseases, CDC. Michael N. Oxman, MD, Professor, University of California, San Francisco; Staff Physician, Infectious Disease Section, VA Medical Center, San Diego. Kristin Nichol, MD, MPH, Chief of Medicine, Minneapolis VA Medical Center; Professor of Medicine and Vice Chair, Department of Medicine, University of Minnesota.

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Natural History, Epidemiology, and Health Burden of Herpes Zoster and PHN

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Varicella Exposure Silent Reactivation? VZV T Cells Zoster Threshold Herpes Zoster Varicella Age Natural History of Herpes Zoster VZV = varicella-zoster infection Adapted from Kost RG, Straus SE. N Engl J Med. 1996;355:32-42; Hope-Simpson RE. Proc R Soc Med . 1965;58:9-20.

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Case Study

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Case Study 1 A 61-year-old lady was as of late determined to have growth in her left bosom and experienced port position for chemotherapy. A few days after the fact she created copying, tingling, and extreme agony to her left side mid-section (close to the port site), arm, and back A couple days after the fact, she built up a vesicular rash She was not able rest in light of unbearable uneasiness She can\'t endure even contact with garments to the influenced range

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Herpes Zoster Rash Photo gave graciousness of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital.

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? What calculates this current patient\'s history may have inclined her to the improvement of herpes zoster? 0 DECISION POINT Use your keypad to vote now! Hindered cell resistance because of propelling age, illnesses, or immunosuppressive treatment Psychological stretch Physical injury All of the above None of the above

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Risk of Herpes Zoster Lifetime danger of herpes zoster is evaluated to be 1 in 5 people 1 half of people living until 90 years old will create herpes zoster 2 Risk variables for herpes zoster incorporate Advancing age 1-3 (lessened VZV-particular cell-interceded insusceptibility [CMI Family history 4 Global diminishment in CMI HIV/AIDS 1,2 Hematologic and neoplastic threat 1,2 Bone marrow and organ transplants 1,5 Immunosuppressive treatment 1,2 Psychological push 6 Physical injury 6 1 Gnann JW Jr, Whitley RJ. N Engl J Med. 2002;347:340-346; 2 Johnson RW, Whitton TL. Master Opin Pharmacother . 2004;5:551-559; 3 Levin MJ et al. J Infect Diseases . 2008;197:825-835; 4 Hicks LD et al. Curve Dermatol . 2008;144:603-608. . 5 Kawasaki H et al. J Pediatr . 1996;128:353-356; 6 Thomas SL, Hall JA. Lancet Infect Dis . 2004;4:26-33. 13

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Incidence of Herpes Zoster Increases With Age Estimated 1 million cases in the United States every year, which will probably increment as populace ages 2000 Women 1629 Men 1500 1122 1118 Rate Per 100,000 Person-Years 1000 876 640 495 500 318 307 262 201 194 184 121 90 54 39 0-14 15-24 25-34 35-44 45-54 55-64 65-74 ≥ 75 Age (Years) Donahue JG et al. Curve Intern Med . 1995;155:1605-1609; Oxman MN et al. N Engl J Med. 2005;352:2271-2284.

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Complications of Herpes Zoster Gnann JW Jr, Whitley RJ. N Engl J Med . 2002;347:340-346; Arvin AM. Clin Microbiol Rev . 1996;9:361-381; Moriuchi K, Rodriguez W. Pediatr Infect Dis J . 2000;19:648-653.

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Postherpetic Neuralgia Chronic neuropathic torment that holds on or creates after herpes zoster rash has mended 1 Recent definitions incorporate torment 90-120 days after rash onset 1-3 Clinical elements of PHN incorporate 2 Constant throbbing and blazing, discontinuous lancinating or wounding torment, allodynia, hyperpathia Risk variables incorporate 3 Advancing age, seriousness of intense torment and rash, difficult prodrome, and number of influenced dermatomes Frequency and seriousness increment with propelling age 4 1 Oxman MN et al. N Engl J Med. 2005;352:2271-2284; 2 Wood MJ, Easterbrook P. Shingles, scourge of the elderly. In: Sacks SL et al, eds. Clinical Management of Herpes Viruses . Amsterdam: IOS Press; 1995:193-209; 3 Jung BF. Neurology . 2004;62:1545-1551; 4 Levin MJ et al. J Infect Dis . 2008;197:825-835. 16

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Impact of PHN on Quality of Life in Older Adults Schmader KE. Clin J Pain . 2002;18:350-354; Chidiac C et al. Clin Infect Dis . 2001;33:62-69; Lydick E et al. Qual Life Res . 1995; 4:41-45; Katz J et al. Clin Infect Dis . 2004;39:342-348; Coplan PM et al. J Pain . 2004;5:344-356.

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Diagnosis of Herpes Zoster 18

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Acute Herpes Zoster: Clinical Manifestations Prodrome of dermatomal torment ≥ 2-5 days Rash attributes Initially maculopapular, then vesicular with an erythematous base Unilateral, despite the fact that can somewhat cover midline Usually includes 1 or 2 dermatomes May be connected with torment or other unusual sensations Evolves more than 7-10 days, recuperating over next 2-4 weeks Reactivation may include torment without rash (zoster sine herpete) Oxman MN. Clinical indications of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246-275.

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Acute Herpes Zoster Rash Order of rash movement Vesicles Pustular sores Lesions outside layer over Resolution of rash Photo and slide graciousness of John W Gnann, Jr, MD.

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Herpes Zoster Rash Photo gave affability of Dr. Kenneth Schmader, Associate Professor of Medicine – Geriatrics, Duke University School of Medicine.

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Trigeminal Zoster Photo gave politeness of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital.

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Pitfalls in Diagnosis Prodrome of intense agony and paresthesias might be mixed up for other agonizing conditions 1 Migraine, glaucoma, myocardial localized necrosis, pleurisy, duodenal ulcer, cholecystitis, a ruptured appendix, and biliary or renal colic Rash can seem like different rashes Zosteriform herpes simplex is the most continuous mistake in conclusion 2 Can be straight, however mends all the more quickly, is probably going to have less torment, and may repeat in same territory 2 If demonstrated, just solid approach to recognize the two is with lab testing (PCR, culture, DFA) 2,3 Occasional disarray with contact dermatitis DFA = coordinate immunofluorescence measure; PCR = polymerase chain response. 1 Oxman MN. Clinical indications of herpes zoster. In: Arvin AM, Gershon AA, eds. Varicella-Zoster Virus: Virology and Clinical Management. Cambridge, UK: Cambridge University Press; 2000:246-275; 2 R űbben An et al. Br J Dermatol . 1997;137: 256-261; 3 Gershon AA et al. Varicella-zoster infection. In: Murray PR et al, eds. Manual of Clinical Microbiology . sixth ed. Washington, DC: ASM Press; 1995:884-894. 23

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Recurrent Herpes Simplex Photo gave kindness of M. Susan Burke, MD, Director, Internal Medicine Clinical Care Center, Lankenau Hospital. 24

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Contact Dermatitis Reprinted with authorization from DermNet. Accessible at: http://dermnet.com. Gotten to February 4, 2008.

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Treatment Strategies for Herpes Zoster and PHN 26

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Case Study 1 (cont\'d) The patient was begun on V alacyclovir 1000 mg 3 times each day for 7 days Oxycodone 10 mg/acetaminophen 650 mg each 4-6 hours as required Gabapentin 300 mg, titrated up to 300 mg tid throughout the following 2 weeks Silver sulfadiazine cream connected 1-2 times each day, and diphenhydramine 25 mg like clockwork as required for tingling

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? Antiviral treatment directed inside 72 hours of rash onset can dependably anticipate PHN 0 DECISION POINT Use your keypad to vote now! 28 True False Unsure

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Pharmacologic Management of Herpes Zoster: Antivirals Most broadly utilized treatment Nucleoside analogs square popular replication 1 and advance rash recuperating 2 3 specialists accessible Acyclovir 3 : 800 mg 5x every day, 7-10 days Famciclovir 4 : 500 mg q8h, 7 days Valacyclovir 5 : 1000 mg 3x every day, 7 days Shown to quicken rash mending and determination of intense torment (days 1-30) 1 Effective when directed inside 72 hours of rash onset; viability past 72 hours is obscure 1,6 Do not dependably avoid PHN 1,6 1 Kost RG, Straus SE. N Engl J Med. 1996;335:32-42; 2 Gnann JW Jr, Whitley RJ. N Engl J Med. 2002;347:340-346; 3 Zovirax [package insert]. Look into Triangle Park, NC: GlaxoSmithKline; 2004; 4 Famvir [package insert]. East H an o ver, NJ: Novartis Pharmaceuticals; 2002; 5 Valtrex [package insert]. Inquire about Triangle Park, NC: GlaxoSmithKline; 2005; 6 Mounsey

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