Subcutaneous Injection of Triamcinolone and Lidocaine to Prevent Postherpetic Neuralgia

Eku Oben, Mercer University College of Pharmacy

Postherpetic neuralgia (PHN) is a complication of herpes zoster, with a 4.2% increase in risk with an increase in age[1] Guidelines for the treatment of herpes zoster (HZ) recommend antivirals as first line therapy. However, this treatment has not been shown to prevent PHN. Zostavax® (zoster vaccine live), is 51.3% effective in preventing herpes zoster and 66.5% effective in preventing PHN. It is also recommended for patients 60 years and older in preventing the onset of herpes zoster and PHN. [2] Topical Lidoderm® (lidocaine) 5% patch is recommended as first-line treatment for PHN. [3] This study shows the effect of using a combination of drugs to prevent PHN, and the use of a subcutaneous injectable lidocaine formulation, as opposed to the well-studied patch in preventing PHN. [4]

Design Randomized prospective clinical trial; N= 100
Objective To determine the effectiveness of subcutaneous injection of triamcinolone and lidocaine in preventing postherpetic neuralgia (PHN)
Study Group Patients receiving standard treatment for herpes zoster (HZ) (n= 50); patients receiving standard treatment for HZ plus subcutaneous injection of triamcinolone and lidocaine (n= 50)
Methods Patients were asked to quantify the average pain experienced in the last 24 hours on a numeric rating scale (NRS) ranging from 0= no pain to 10= worst pain ever.

 

Quality of life (QoL) was measured by a medical outcomes study short-form (SF-36).

 

Follow ups were done at one, three, and six months post rash onset and patients were asked to assess the severity of HZ pain in the past 24 hours.

 

SF-36 scores were assessed at months three and six after rash, to evaluate QoL.

Duration May 1, 2014 – April 30, 2015
Primary Outcome Measure The presence of zoster-associated pain (ZAP) with a numeric rating scale (NRS) score of three, at three months after rash onset
Baseline Characteristics
  Standard group (n= 50) Subcutaneous group (n= 50)
Age at rash onset (mean ± SD) 63.84±10.2 65.86±10.19
Gender (male/female) 23/27 24/26
Duration of pain after rash onset (days, mean ±SD) 3.2±1.96 3.36±1.35
Pain NRS at inclusion (mean ±SD) 6.64±1.44 7.16±1.22
Localization
Face 8 (16%) 7 (14%)
Cervical region 5 (10%) 2 (4%)
Thoracic region 23 (46%) 31 (62%)
Lumbar region 14 (28%) 10 (20%)

SD= standard deviation

Results
 
Patients with ZAP (%) One month Three months Six months
Standard therapy group 12 (24%) 10 (20%) 9 (18%)
Subcutaneous injection group 3 (6%) 2 (4%) 2 (4%)
RR (95% CI) 082 (0.68 to 0.96) 0.83 (0.72 to 0.97) 0.85 (0.74 to 0.98)
p value 0.012 0.014 0.025

 

Adverse Effects Common: Self-limiting subcutaneous hemorrhage n= 8 (16%); Pain at injection site n= 7 (14%)
Serious: none reported
Percentage that discontinued due to adverse events: none reported
Study Author Conclusions Subcutaneous injection of triamcinolone and lidocaine, combined with standard HZ treatment is effective and safe in treating pain caused by HZ and in preventing PHN.

The study showed a positive effect when standard HZ treatment was combined with subcutaneous triamcinolone and lidocaine in treating HZ and preventing PHN when compared to standard HZ treatment alone. Patients in the subcutaneous group had a lower incidence of zoster associated pain compared to patients in the standard group at month one (p= 0.012), month three (p= 0.014) and month six (0.025). However, this study did not include a placebo subcutaneous injection in the standard group, which could be a limitation in terms of both groups being treated equally. In addition, the small sample size, coupled with the study being carried out in a single center, could be a limitation as it may not be representative of the entire population.

 

 

References

[1] Cebrian-Cuenca A, Diez-Domingo J, San-Martin-Rodriguez M, Puig-Barbera J, Navarro-Perez. Epidemiology and cost of herpes zoster and postherpetic neuralgia among patients treated in primary care centres in the valencian community of Spain. BMC Infect Disease. 2011;11:302.

[2] Fashner J, Bell A. Herpes zoster and postherpetic neuralgia: prevention and management. Am Fam Physician. 2011;83(12):1432-1437.

[3] Dubinsky R, Kabbani H, El-Chami Z, Boutwell C, Ali H. Practice Parameter: Treatment of postherpetic neuralgia. Neurol. 2004;63(6):959-965.

[4] Ni J, Wang X, Tang Y, Yang L, Zeng Y, Guo Y. Subcutaneous Injection of Triamcinolone and Lidocaine to Prevent Postherpetic Neuralgia. Pain Physician. 2017;20(5):397-403.

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