Case Study: Shingles

Case 1: Shingrix Vaccine

Q: SC is a 51-year-old man who has hyperlipidemia, hypertension, and shingles, which was diagnosed 3 months ago. During his acute shingles episode, he experienced a blistering rash along his back and managed symptoms at home with OTC acetaminophen and calamine lotion. SC is up-to-date on all vaccines except for the recombinant zoster vaccine (Shingrix). Now that he has fully recovered, he asks the pharmacist whether he is eligible to receive the recombinant zoster vaccine based on his age and recent history of herpes zoster.

A: SC is eligible to receive the recombinant zoster vaccine, according to the CDC. Adults 50 years and older should get 2 doses of the recombinant zoster vaccine, separated by 2 to 6 months. Patients who have had shingles can receive the recombinant zoster vaccine to help prevent future reoccurrences. There is no specific length of time patients should wait after having shingles before they can receive the recombinant zoster vaccine, but they should not receive it if they have an acute episode of shingles. In addition, patients with moderate or severe sickness, with or without a fever, should wait until they recover before receiving the vaccine.¹ The recombinant zoster vaccine is contraindicated in patients with a history of severe allergic reactions to any component of the vaccine or previous dose.²

Case 2: Drug-Drug Interaction

Q: VS is a 49-year-old woman who is picking up a valacyclovir (Valtrex) prescription for the management of shingles. She researched valacyclovir online and saw that it interacts with cimetidine, an OTC medication she takes for heartburn. VS is reluctant to take the valacyclovir because of potential drug-drug interactions. Aside from heartburn, she is healthy and has no past medical problems. What should the pharmacist recommend?

A: Cimetidine is a weak cytochrome P450 1A2 inhibitor and may increase the serum concentration of valacyclovir.^3,4 The risk rating of this reaction is Category B, according to the National Institutes of Health, which means no action is needed and the medications can be taken together without any dose adjustments if the patient has normal renal function.^4,5 VS may safely take the valacyclovir for the treatment of herpes zoster. If she is uncomfortable with this interaction, she may consider temporarily switching to famotidine (Pepcid AC) to manage the heartburn, as this alternative does not have interactions with valacyclovir.⁴

Case 3: Shingles Pain Management

Q: RT is a 50-year-old woman who is taking acyclovir for a new diagnosis of shingles. She asks whether there are medications that will relieve her symptoms. RT complains of mild pain that she rates 3 out of 10, along with a persistent itch, despite starting antiviral therapy. What should the pharmacist recommend?

A: OTC medications that can be used for the short-term management of pain secondary to shingles include acetaminophen (Tylenol) and nonsteroidal anti-inflammatory drugs, such as ibuprofen (Advil).^6,7 These oral OTC medications can relieve mild to moderate pain caused by the shingles virus. In addition to oral medications, patients may use topical agents such as capsaicin and lidocaine,⁶ which are available in multiple topical preparations, including creams and patches.⁶ Creams may be applied to the skin 3 to 4 times daily as needed for relief. Topical patches should be applied to a clean, dry area of the skin, and the patient should refer to the manufacturer’s labeling regarding product-specific recommendations on administration. If the pain becomes severe or worsens, refer RT to a physician for further treatment. Calamine lotion, colloidal oatmeal baths, and wet compresses may be recommended to help relieve itching.⁷

Case 4: Zostavax Vaccine

Q: OP is a 66-year-old woman who is complaining about a painful red blister rash with a tingling sensation. She shares that her neighbor experienced similar symptoms several years ago and received a shingles diagnosis. OP received the shingles vaccine, zoster vaccine live (Zostavax), when she turned 60 and asks whether she is still protected from shingles. Are there any preventive measures OP should take?

A: The pharmacist should inform OP that vaccination is the most effective preventive measure for shingles. The zoster vaccine live reduces the risk of herpes zoster by 51%, with protection lasting only approximately z5 years, and it is no longer available in the United States.⁸ Recombinant zoster vaccine (Shingrix) is the preferred shingles vaccine.1The ZOE-50 trial (NCT01165177) assessed the efficacy of recombinant zoster vaccine compared with a placebo in reducing the risk of herpes zoster in adults 50 years and older. The study demonstrated that recombinant zoster vaccine was 96.6% effective in preventing herpes zoster in individuals aged 50 to 59 years and 97.4% effective in those aged 60 to 69 years. The CDC recommended that recombinant zoster vaccine be used in adults 50 years and older, irrespective of prior receipt of zoster vaccine live.⁹ After OP recovers from this acute episode, she is eligible for recombinant zoster vaccine to improve her protection against herpes zoster.

References

1. Shingrix recommendations. CDC. Updated January 24, 2022. Accessed January 6, 2023. https://www.cdc.gov/vaccines/vpd/shingles/hcp/shingrix/recommendations.html
2. Shingrix. Prescribing information. GSK; 2021. Accessed January 19, 2023. www.fda.gov/media/108597/download
3. Drug development and drug interactions | table of substrates, inhibitors and inducers. FDA. Updated August 24, 2022. Accessed January 6, 2023. https://www.fda.gov/drugs/drug-interactions-labeling/drug-development-and-drug-interactions-table-substrates-inhibitors-and-inducers
4. Valtrex. Prescribing information. GSK; 2008. Accessed January 19, 2023. www.accessdata.fda.gov/drugsatfda_docs/label/2008/020487s014lbl.pdf
5. Valacyclovir. In: Lexi-Drugs. Lexicomp, Inc. Updated December 3, 2022. Accessed December 12, 2022.[YQ1]
6. Saguil A, Kane S, Mercado M, Lauters R. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2017;96(10):656-663.
7. Treating shingles. CDC. Updated December 9, 2020. Accessed January 6, 2023. https://www.cdc.gov/shingles/about/treatment.html
8. What everyone should know about Zostavax. CDC. Updated October 5, 2020. Accessed January 6, 2023. https://www.cdc.gov/vaccines/vpd/shingles/public/zostavax/index.html
9. Dooling KL, Guo A, Patel M, et al. Recommendations of the Advisory Committee on Immunization Practices for use of herpes zoster vaccines. MMWR Morb Mortal Wkly Rep. 2018;67(3):103-108. doi:10.15585/mmwr.mm6703a5

About the Authors

Nicole Rudawsky, PharmD, BCPS, is a clinical assistant professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway.

Rupal Mansukhani, PharmD, FAPHA, CTTS, is a clinical associate professor of pharmacy practice and administration at the Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey in Piscataway and a transitions-of-care clinical pharmacist at Morristown Medical Center.