Pharmacists Should Recommend Vaccine to Prevent Shingles and Lower Risk for Postherpetic Neuralgia
Adult vaccination rates are notoriously low and they’re especially poor for the herpes zoster vaccine. While most elderly adults are familiar with the flu vaccine, many aren’t aware there’s a vaccine to prevent shingles and postherpetic neuralgia—even fewer understand their risk for a shingles outbreak.
Through outreach and patient education, community pharmacists can increase vaccination rates in this vulnerable population. As you help older adults prevent the pain of shingles and avoid the intense challenge of postherpetic neuralgia, you can also support your business if you choose to offer in-store vaccinations.
Millions of Patients At Risk for Shingles
An eye-opening number of people are at risk for shingles and postherpetic neuralgia. Data from 2015 shows that about 88,680,000 people in the U.S. are aged 55 years or older.1 Nearly half of them fall between the ages of 55 and 64, so the other half are 65 and over. The following numbers fill in the story for these adults2:
- One in three will develop shingles.
- One in five will develop postherpetic neuralgia (PHN).
- Risk of PHN increases with age – 60 percent of those over 60 develop PHN.3
- Herpes zoster vaccine cuts the risk for shingles in half.
- Herpes zoster vaccine cuts the risk for postherpetic neuralgia by 67 percent.
- Only 24 percent of adults aged 60 and older have received the vaccine.
The statistics represent a major concern. In addition to the obvious physical trauma from shingles and PHN, age-related health decline and a weakened immune system increase the risk of an outbreak leading to hospitalization. All of which highlights the need to encourage patients aged 60 and over to get the herpes zoster vaccine to prevent shingles.
Overview of Shingles, Postherpetic Neuralgia, and Treatment Options
After exposure to chickenpox, the varicella virus settles into the dorsal root ganglia of sensory nerves and stays dormant for years. As patients age, and especially after the age of 50, the virus can reactivate. Then it spreads along cutaneous neurons, replicates in the epidermis and triggers an outbreak of shingles, or herpes zoster. The outbreak goes through three clinical phases, which have the following symptoms:
Pre-eruptive Phase – lasts about 48 hours:
- Pain, tingling and itching occur along skin dermatomes.
- Pain can mimic headache, iritis, pleurisy, cardiac pain, brachial neuritis, sciatica, or appendicitis.
- Malaise, myalgia, and photophobia may develop.
Acute Eruptive Phase – symptoms heal over 10-15 days; complete healing may take 4 weeks:
- Skin eruption is usually unilateral.
- Severe pain accompanies the rash.
- Regional lymphadenopathy develops.
- Skin manifestations include patchy erythema with clusters of herpetiform vesicles that gradually turn cloudy, rupture, crust, involute and slowly heal.
Chronic Phase – Postherpetic Neuralgia:
- Severe and incapacitating pain after lesions have crusted—persists for months or years.
- Higher risk in patients with upper-body dermatomal involvement and with herpes zoster ophthalmicus.
- Hyperesthesia may be present in some patients.
Treatment for shingles: Prompt medical treatment can shorten the duration of the outbreak, relieve pain and help lower the risk of PHN. Therapy may include any of the following:
- Antiviral drugs – acyclovir, valacyclovir and famciclovir
- Capsaicin cream
- Anticonvulsants – gabapentin
- Tricyclic antidepressants – amitriptyline
- Numbing topical agents – lidocaine
Treatment for postherpetic neuralgia: While pain management is the primary goal, therapy is often needed for other PHN-related problems, such as difficulty sleeping and changes in mood or physical functioning. Treatment may be complicated by polypharmacy, so pharmacists need to watch for drug-drug interactions. Since the pathophysiology of PHN may involve peripheral and central processes, using multiple agents with differing mechanisms of action leads to the best results.4
- Gabapentin or pregabalin
- Lidocaine 5% topical treatment
- Tricyclic antidepressants
- Capsaicin 8% patch or 0.075% cream
- Opioids – although not FDA approved may be considered for severe pain
Patients with PHN face a complex regimen that makes compliance a challenge. In addition to topical treatments and polypharmacy, doses of gabapentinoids may need to be titrated or require multiple daily doses. You can improve adherence by recommending gastroretentive gabapentin and by helping patients assemble a pill box that incorporates all of their medications.
Herpes Zoster Vaccine Benefits Patients and Pharmacists
Any number of roadblocks explain why patients don’t get the herpes zoster vaccine. They may not know the risk for shingles and PHN, so a vaccine isn’t on their radar. Or they might not remember having chickenpox so they think they’re safe. If they already had a shingles outbreak, patients may not realize it’s still smart to get the vaccine to prevent future outbreaks. Some will be worried about safety, while for many others, the biggest drawback is the cost because it is an expensive vaccine that’s often paid for out-of-pocket. Here are a few key points to use when counseling elderly patients:
- Stress that age is the biggest risk factor and that no one is too old to get the vaccine.
- Zostavax is approved for anyone aged 50 and over, but it’s only recommended for patients aged 60 and older because efficacy wanes after 7 to 10 years.
- Advise patients to get the vaccine even if they don’t remember having chickenpox.
- Stress that the vaccine has been used for years, has a good safety record, and is well tolerated.
- Be up-front about the costs and have them check with their insurance provider for coverage.
- Refer them to the Merck patient assistance program for Zostavax.5
Pharmacists can influence their patients to consider the vaccine through education and by helping them find financial options. You could also make it more accessible and convenient by offering Zostavax at your pharmacy. Beyond the benefit of promoting the health of elderly patients in the community, you should be able to add to your pharmacy’s bottom line. A retrospective review of pharmacy records published in the January 2009 issue of the Journal of the American Pharmacists Association found that revenues from administering the herpes zoster vaccine yielded a net profit of 8.15 percent per vaccination.6
Pharmacist Intervention Increases Herpes Zoster Vaccination Rates
Even if you don’t provide vaccinations on-site, face-to-face interaction with your elderly patients goes a long way toward motivating them to get the herpes zoster vaccine to prevent shingles. Other outreach efforts like flyers, putting up posters, or even running ads in the local newspaper can also boost vaccination rates. Every effort you make, whether alone or in collaboration with a local physician, helps ensure older patients maintain an active and healthy life.
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- “Population Distribution by Age,” 2015, http://kff.org/other/state-indicator/distribution-by-age/?dataView=1¤tTimeframe=0 ↩
- “Shingles Surveillance,” August 2016, http://www.cdc.gov/shingles/surveillance.html ↩
- “Postherpetic Neuralgia,” November 2016, http://emedicine.medscape.com/article/1143066-overview ↩
- “Practical Considerations in the Pharmacological Treatment of Postherpetic Neuralgia for the Primary Care Provider,” March 2014, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3956687/ ↩
- “Merck Patient Assistance Program: Zostavax,” accessed December 2016, http://www.merckhelps.com/ZOSTAVAX ↩
- “Retrospective Financial Analysis of a Herpes Zoster Vaccination Program From an Independent Community Pharmacy Perspective,” January 2009, https://www.ncbi.nlm.nih.gov/pubmed/19196591/ ↩