Practice Parameter: Treatment of postherpetic neuralgia: [RETIRED]

Abstract

Abstract-A systematic review of the literature on postherpetic neuralgia was performed. The authors identified studies using the National Library of Medicine's Medline database and Cochrane Library database. The authors determined absolute reduction rate, number needed to treat (NNT), 95% CI for NNT, and number needed to harm (NNH) for successful therapies of postherpetic neuralgia. Tricyclic antidepressants, gabapentin, pregabalin, opioids, and lidocaine patch were found to be effective in reducing the pain of postherpetic neuralgia. NEUROLOGY 2004;63:959 -965 Acute herpetic neuralgia is characterized as burning, aching, electric shock like pain, or unbearable itching in association with the outbreak of a herpes zoster rash. The pain is associated with dysesthesias, paresthesias, hyperalgesia, hyperesthesia, and allodynia (production of pain by innocuous stimuli).1 The pain may precede the onset of the herpetic rash and, rarely, herpetic neuralgia can occur without the development of a rash.2 Postherpetic neuralgia, persistence of the pain of herpes zoster more than 3 months after resolution of the rash, is relatively common, affecting 10 to 15% of those with herpes zoster. Zoster-associated pain is used to describe the continuum of pain from acute herpes zoster to the development of postherpetic neuralgia. The time interval used in the clinical case definition of postherpetic neuralgia varies in the literature from 1 to 6 months after resolution of the rash. The incidence of postherpetic neuralgia increases with age. 3 The duration of postherpetic neuralgia is highly variable. In a longitudinal study, of those who developed postherpetic neuralgia, only 48% were symptomatic 1 year after onset.4,5 A prospective study of postherpetic neuralgia, performed through a network of primary care providers in Iceland from 1990 to 1995, showed that 14 of the 25 who developed postherpetic neuralgia were symptomatic 12 months after onset.6 Thus, the natural history of resolution of postherpetic neuralgia over time is a confounder in the evaluation of treatment efficacy and may limit the ability to generalize the results of controlled clinical trials in this population.Administration of antiviral agents within 72 hours of the onset of herpes zoster can reduce the intensity and duration of acute illness, and can prevent postherpetic neuralgia, 7 as may the use of amitriptyline.8 Efforts at prevention of herpes zoster and postherpetic neuralgia are important in that 40 to 50% of those with postherpetic neuralgia do not respond to any treatment. 9 The treatment of acute herpes zoster 10 and the prevention of postherpetic neuralgia are beyond the scope of this parameter.This practice parameter was developed to answer the following clinical question: In patients with postherpetic neuralgia, which treatments provide benefit in terms of decreased pain and improved quality of life?Process. We searched the National Library of Medicine's Medline database and the Cochrane database for peer-reviewed articles published between

Evidence-Based Case Report

“…Our levels of evidence are in agreement with the assessments of the Quality Standards Subcommittee of the American Academy of Neurology. 75 There is a need for randomized controlled studies on the efficacy of interventional treatments of PHN either because drugs are not always effective, as shown in our case report, or because their adverse effects limit their dose. Intrathecal alcohol should be considered only in resistant cases of PHN.…”

“…RCTs support efficacy *Two studies showed the efficacy of topical capsaicin, but the magnitude of pain relief may not be clinically important. 75 RCT indicates randomized controlled trial. …”

Lidocaine plasters for postherpetic neuralgia?

“…Two further systematic reviews9 , 10 of evidence on treatments for postherpetic neuralgia both included the randomised trials described above,5 , 6 and also a trial of 5% lidocaine gel applied topically 11. The authors of both reviews concluded that topical lidocaine was effective in reducing the pain of postherpetic neuralgia based on strength of evidence and low level of unwanted effects.…”

Controlled-Release Oxycodone in the Treatment of Neuropathic Pain of Nonmalignant and Malignant Causes

“…Opioids have been shown to be effective in the treatment of postherpetic neuralgia [5] and painful diabetic neuropathy [6]. Opioids are included in the current treatment guidelines by the American Academy of Neurology for the treatment of postherpetic neuralgia [7] and by the European Federation of Neurological Sciences for painful polyneuropathy [8] based on these studies. Despite this growing body of evidence supporting their use, clinicians hesitate to administer opioids to a patient with severe neuropathic pain unrelieved by standard treatment.…”