Corticosteroids for preventing postherpetic neuralgia

Corticosteroids for preventing postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia (PHN) is a common, serious, painful complication of herpes zoster. Corticosteroids have anti-inflammatory properties, and might be beneficial. This is an update of a review first published in 2008, and previously updated in 2013.

OBJECTIVES

To assess the effects (benefits and harms) of corticosteroids in preventing postherpetic neuralgia.

SEARCH METHODS

We updated the searches for randomised controlled trials (RCTs) of corticosteroids for preventing postherpetic neuralgia in the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, Embase, two other databases, and two trials registers (June 2022). We also reviewed the bibliographies of identified trials, contacted authors, and approached pharmaceutical companies to identify additional published or unpublished data.

SELECTION CRITERIA

We included all RCTs involving corticosteroids given by oral, intramuscular, or intravenous routes for people of all ages, with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo, but not with other treatments.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified potential articles, extracted data, assessed the risk of bias of each trial, and the certainty of the evidence. Disagreement was resolved by discussion among the co-authors. We followed standard Cochrane methodology.

MAIN RESULTS

We identified five trials with a total of 787 participants that met our inclusion criteria. No new studies were identified for this update. All were randomised, double-blind, placebo-controlled parallel-group studies. The evidence is very uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection in preventing postherpetic neuralgia six months after the onset of herpes (risk ratio (RR) 0.95, 95% confidence interval (CI) 0.45 to 1.99; 2 trials, 114 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)). The three other trials that fulfilled our inclusion criteria were not included in the meta-analysis because they did not provide separate information on the number of participants with PHN at six months. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no observed differences in serious (RR 1.65, 95% CI 0.51 to 5.29; 5 trials, 755 participants; very low-certainty evidence (downgraded for serious risk of bias and very serious imprecision)), or non-serious adverse events (RR 1.30, 95% CI 0.90 to 1.87; 5 trials, 755 participants; low-certainty evidence (downgraded for serious risk of bias and serious imprecision)) between the corticosteroid and placebo groups. One of these trials was at high risk of bias because of incomplete outcome data, two were at unclear risk of bias, and the other was at low risk of bias. The review was first published in 2008; no new RCTs were identified for inclusion in subsequent updates in 2010, 2013, and 2023.

AUTHORS' CONCLUSIONS

Based on the current available evidence, we are uncertain about the effects of corticosteroids given orally during an acute herpes zoster infection on preventing postherpetic neuralgia. Corticosteroids given orally or intramuscularly may result in little to no difference in the risk of adverse events in people with acute herpes zoster. Some researchers have recommended using corticosteroids to relieve the zoster-associated pain in the acute phase of the disease. If further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life, as well as updated measures of pain.

Methylprednisolone and local anesthetic for Long-term Postherpetic Neuralgia: a meta-analysis

OBJECTIVE

The purpose was to evaluate the efficacy of methylprednisolone combined with local anesthetics on the incidence or intensity of long-term PHN.

METHODS

We have performed comprehensive literature research in PubMed, Web of Science, Cochrane library, and China national knowledge infrastructure (CNKI) databases (inception through October 19, 2021). Relevant randomized controlled trials(RCTs) with long-term duration were included, regardless of the injection method. The indicators were the incidence of PHN and the Visual Analog Scale (VAS) scores.

RESULTS

Five randomized controlled trials with 980 patients were retrieved. Compared with standard treatment (antivirals) alone, the combination of methylprednisolone, local anesthetic and standard treatment exhibited a significant decrease in the incidence of PHN in 1 month (RR =0.38, 95%CI: 0.19 to 0.76), 3 months (RR =0.40, 95%CI: 0.19 to 0.84) and 6 months (RR =0.37, 95%CI: 0.15 to 0.94) after zoster onset. In VAS scores, there was also a significant difference between the two groups in long-term PHN (3 months: WMD=-1.57, 95%CI: -2.84 to -0.30; 6 months: WMD=-0.72, 95%CI: -1.29 to -0.16).

CONCLUSION

The combination of Methylprednisolone, local anesthetic, and standard treatment appears to be an ideal option for patients with PHN. Further investigation is needed for the safety of this therapy.

Infections and glaucoma

Glaucoma is an intraocular pressure-related ophthalmic disease with multiple causes that results in an optic neuropathy and vision loss. Intraocular pressure elevation is among its strongest risk factors. While glaucoma is mostly primary in etiology, secondary glaucoma is not infrequent. Recognizing its cause is imperative, since treatment is often different depending on the pathophysiologic mechanism. Numerous clinically relevant ophthalmic infections can result in robust inflammatory responses that may result in pressure elevation or intraocular anatomic configurations that predispose to pressure elevation. Knowing the mechanisms by which these infections can lead to glaucoma is critical in treating, and we consolidate what is currently known in regards to how infectious diseases lead to glaucoma.

Zoster-associated limb paralysis mimicking acute stroke: a case report

Background

Varicella zoster virus is a Deoxyribonucleic acid (DNA) virus exclusively affecting humans. Reactivation of varicella zoster virus causes herpes zoster with vesicular eruptions in a restricted dermatomal distribution. Peripheral motor neuropathy is a very rare complication of varicella zoster virus.

Case presentation

A 57-year-old previously well Sri Lankan female presented with acute onset painful weakness of the left upper limb with a preceding history of a febrile illness. Subsequently she developed vesicular eruptions in the dermatomal distribution of cervical 5, 6, and 7. Electromyography was suggestive of acute denervation of cervical 5, 6, and 7 myotomes. Diagnosis of zoster-associated brachial plexopathy was made, and the patient was treated with acyclovir, steroids, and analgesics. She made a good recovery.

Conclusion

Brachial plexus neuritis due to varicella zoster infection should be considered in an acute monoparesis of a limb as it is a treatable and reversible condition

Corticosteroids for preventing postherpetic neuralgia

BACKGROUND

Postherpetic neuralgia is a common, serious painful complication of herpes zoster. Corticosteroids are anti-inflammatory and might be beneficial. This is an update of a review first published in 2008 and previously updated in 2010.

OBJECTIVES

To examine the efficacy of corticosteroids in preventing postherpetic neuralgia.

SEARCH METHODS

We updated the searches for randomised controlled trials (RCTs) of corticosteroids for preventing postherpetic neuralgia in the Cochrane Neuromuscular Disease Group Specialized Register (16 April 2012), CENTRAL (2012, Issue 3), MEDLINE (January 1966 to April 2012), EMBASE (January 1980 to April 2012), LILACS (January 1982 to April 2012), and the Chinese Biomedical Retrieval System (1978 to 2012). We also reviewed the bibliographies of identified trials, contacted authors and approached pharmaceutical companies to identify additional published or unpublished data.

SELECTION CRITERIA

We included all RCTs involving corticosteroids given by oral, intramuscular, or intravenous routes for people of all ages with herpes zoster of all degrees of severity within seven days after onset, compared with no treatment or placebo but not with other treatments. We did not include quasi-RCTs (trials in which a systematic method of randomisation such as alternation or hospital number was used).

DATA COLLECTION AND ANALYSIS

Two authors identified potential articles, extracted data, and independently assessed the risk of bias of each trial. Disagreement was resolved by discussion among the co-authors.

MAIN RESULTS

Five trials were included with 787 participants in total. All were randomised, double-blind, placebo-controlled parallel-group studies. We conducted a meta-analysis of two trials (114 participants) and the results gave moderate quality evidence that oral corticosteroids did not prevent postherpetic neuralgia six months after the onset of herpes (RR 0.95, 95% CI 0.45 to 1.99). One of these trials was at high risk of bias because of incomplete outcome data, the other was at low risk of bias overall. The three other trials that fulfilled our inclusion criteria were not included in the meta-analysis because the outcomes were reported at less than one month or not in sufficient detail to add to the meta-analysis. These three trials were generally at low risk of bias. Adverse events during or within two weeks after stopping treatment were reported in all five included trials. There were no significant differences in serious or non-serious adverse events between the corticosteroid and placebo groups. There was also no significant difference between the treatment groups and placebo groups in other secondary outcome analyses and subgroup analyses. The review was first published in 2008 and no new RCTs were identified for inclusion in subsequent updates in 2010 and 2012.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that corticosteroids given acutely during zoster infection are ineffective in preventing postherpetic neuralgia. In people with acute herpes zoster the risks of administration of corticosteroids do not appear to be greater than with placebo, based on moderate quality evidence. Corticosteroids have been recommended to relieve the zoster-associated pain in the acute phase of disease. If further research is designed to evaluate the efficacy of corticosteroids for herpes zoster, long-term follow-up should be included to observe their effect on the transition from acute pain to postherpetic neuralgia. Future trials should include measurements of function and quality of life.

Postherpetic neuralgia in the elderly

Postherpetic neuralgia (PHN) is the most common complication of herpes zoster (HZ) or 'shingles' and affects a significant proportion of HZ patients with the disease, with the elderly being most frequently and seriously affected. Characterised by various types of pain (constant, intermittent and stimulus evoked) that persist between 3 months and many years after the resolution of the HZ rash, PHN can have a severe impact on the patient's quality of life and functional ability. PHN remains highly resistant to current treatments. In this review, we discuss the epidemiology, clinical features and management of PHN in the elderly and the potential of vaccination against varicella zoster virus as a means to prevent HZ, and thus decrease the incidence and severity of PHN.