A 70-year-old woman comes to the office after several months of severe pain in her upper back and anterior chest. She used over-the-counter analgesics and a lotion to cope with the pain. The patient stopped using the lotion when it caused a skin rash with blisters. The blisters eventually healed, but she continues to have a severe burning sensation that can be triggered with even a slight touch. The pain interferes with the patient's sleep and daily activities. She has degenerative joint disease and lives independently.
The patient's vital signs are normal. Skin examination is unremarkable except for an area of hyperesthesia along the fourth intercostal space. The remainder of the examination is within normal limits.
Which of the following medications is the most appropriate therapy for this patient?

Question

A 70-year-old woman comes to the office after several months of severe pain in her upper back and anterior chest.  She used over-the-counter analgesics and a lotion to cope with the pain.  The patient stopped using the lotion when it caused a skin rash with blisters.  The blisters eventually healed, but she continues to have a severe burning sensation that can be triggered with even a slight touch.  The pain interferes with the patient's sleep and daily activities.  She has degenerative joint disease and lives independently.
The patient's vital signs are normal.  Skin examination is unremarkable except for an area of hyperesthesia along the fourth intercostal space.  The remainder of the examination is within normal limits.
Which of the following medications is the most appropriate therapy for this patient?

Quizplus · Accepted Answer

This patient has pain along a dermatomal distribution and history of a rash, suggestive of post-herpetic neuralgia (PHN) from herpes zoster, which is caused by reactivation of latent varicella zoster virus infection. Patients usually have a rash, although some may have pain and systemic symptoms (eg, fever, malaise, headache) prior to development of the rash. Management of pain associated with herpes zoster rash is based on the time interval of symptoms. Patients with acute neuritis (pain that persists up to 30 days from rash onset) or subacute neuritis (pain that resolves within 4 months of rash onset) are treated with nonsteroidal anti-inflammatory drugs, acetaminophen, and/or opioid combinations. About 10%-15% of patients with herpes zoster develop PHN, defined as persistent pain 4 months after rash onset. Tricyclic antidepressants (TCAs) such as nortriptyline and desipramine have the most evidence of efficacy. A low dose should be started and slowly titrated to the lowest effective dose. However, due to their side effects (eg, dry mouth, constipation, dizziness, sedation), TCAs are included in the Beers Criteria of potentially inappropriate medications for older adults. Anticonvulsants such as pregabalin or gabapentin are also useful in alleviating the pain of PHN and could be considered in this patient. Opioids and topical lidocaine patches can be used in combination with these agents. (Choice A) Carbamazepine is the most studied and effective treatment for trigeminal neuralgia. There is no evidence to support its use for PHN. (Choice B) Glucocorticoids have not been proven to be helpful for PHN. (Choice D) Capsaicin can be used for moderate PHN pain. However, it causes intolerable stinging, burning, and erythema in one-third of patients and is not recommended as first-line treatment. (Choice E) Antiviral therapy may help decrease the length and severity of symptoms when initiated within 72 hours in patients age >50 with uncomplicated herpes zoster. Acyclovir, famciclovir, or valacyclovir is usually used for 7 days. This patient is well beyond the window for antiviral therapy. Educational objective: Acute neuritis associated with herpes zoster is treated with traditional oral analgesics. Post-herpetic neuralgia (pain that persists months after resolution of the rash) is treated with tricyclic antidepressants, gabapentin, or pregabalin. Antiviral therapy is recommended only for patients who present within 72 hours of initial herpes zoster symptoms. __________ References: Review of current guidelines on the care of postherpetic neuralgia. (http://www.ncbi.nlm.nih.gov/pubmed/21904096) The impact of herpes zoster and postherpetic neuralgia on health-related quality of life: a prospective study. (http://www.ncbi.nlm.nih.gov/pubmed/20921251)

A 70-Year-Old Woman Comes to the Office After Several Months