Treatment For Chronic Pain: (Postherpetic Neuralgia/PHN)

Treatment for Chronic Pain
(Postherpetic Neuralgia/PHN)
dr Putu Sukedana S.Ked
Budiarsana Foundation
@sukedanapt
DREAM
@sukedanapt
Our home until 2017 -
- Our dreams comes true 2018

Case
 Male, 51 years old, feeling pain at left back. 3 month ago become Herpes z
oster at site pain now. He felt burning at that place, what is your diagnose?
Management?
@sukedanapt
1. Saguil, Aaron; Kane, Shawn; Mercado, Michael; Lauters, Rebecca. Herpes Zoster and Postherpetic Neuralgia: Prevention and Management. American Family Physician. 2017;96 (10): 656-663
2. Angkasa, F; Putra, IB; Yosi, A. 2020. Correlation between postherpetic neuralgia (PHN) patients stress level and the quality of life of their families in Universitas umatera Utara Hospital. Bali
Medical Journal 9 (3): 749-752
1 What is Postherpetic Neuralgia/PHN?
2 Epidemiology Postherpetic Neuralgia/PHN
3 Patophysiology
4 Management
@sukedanapt
Postherpetic Neuralgia/PHN
 Pain in a dermatomal distribution that is sustained for at least 90 days after t

he rash1
 Characterized neuropathic type pain: sharp and distinct. Quality pain : burnin
g, shooting and tingling sensation or worse, allodynia, and hyperalgesia2
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Insert Your Image
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Epidemiology Postherpetic Neuralgia/PHN
 Approximately 20% of patients with herpes zoster and 80% of cases occur in
patients 50 years or older.1
 Herpes Zoster/HZ estimated in Asia Pacific: 3-10/1000 person/year. Incidenc
e of PHN is 10%-25%3
 Studied from 13 teaching hospitals in Indonesia, 26,5% patient become PHN
(593 patients from 2.232 cases). From studied of 30 PHN patients, 9 patient
s (30%) mild stress, 16 patients (53.3%) experienced moderate stress; 5 pati
ents (16,7%) severe stress levels2
@sukedanapt
3. Shrestha, Meera; Chen, Aijun. Modalities in managing postherpetic neuralgia. Korean J Pain 2018 October; Vol. 31, No 4
Patophysiology of Herpes Zoster (HZ)
After the primary VZV infection (chickenpox),

latent infection is established in the sensory-
cranial nerve and spinal dorsal root ganglia 1,2,3
The trigeminal and thoracic ganglia are the

most common neuronal sites involved; these
dermatomes are also the most common sites
of cutaneous herpes zoster.
@sukedanapt
1. Kimberlin, David W; Whitley, Richard J. Varicella-Zoster Vaccine for the Prevention of Herpes Zoster. The New England Journal of Medicine 2007; 356: 1338-1343
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of
Multidiciplinary Healthcare 2016:9 447-454
3. Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
Insert Your Image
@sukedanapt
Management Chronic Pain1
 Pharmacology
 Non Pharmacology
Treatment
Treatment
First Line: Tricyclic antidepressant, Nerve block, Stimulation,

Anticonvulsant or topical lidocaine 5% Physioterapy, Psycology
patches
Second or third line: Opioid, NSID, Steroid
OR COMBINATION
 Preventing chronic pain by more aggressive treatment of acute pain, avoid infection with VZV, and
prompt treatment of HZ with oral antiviral agents 1,2
 61.1% reduction of HZ burden illness following vaccination compare than placebo 2. HZ vaccine
decrease the incidence of PHN versus placebo approximately two-thirds 3
1. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
@sukedanapt
2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary
Healthcare 2016:9 447-454
Tricyclic antidepressant
 Available as tablet 10,25,50  Dose started12,5-25 mg

mg oral, usually take it at daily2,3. Increased 12,5-25 mg
Amitriptyline1
night2 every three to five days.3
 Side effect is anticholinergic Maximum dose 250 mg
activity include dry mouth, daily.3
weight gain, conctipation and  Caution in the elderly with
drowsiness 2,3 heart desease, epilepsy or
glaucoma4
Mechanism through inhibit of serotonine and noradrenaline NNT 2.5. Pain relieve
reuptake at CNS1,2 and blocking voltage-dependent sodium 25%-50% of patient
channels and α-adrenergic receptors, actions important in than placebo2,5.
modulating descending pain pathways 5
1. Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
2. R Andrew, Moore; Sheena, Derry; Dominic, Aldington; Peter Cole, Wiffen. Amitriptyline for neuropathic pain in adults (Review). Cochrane Database of Systematic Reviews 2015, Issues 7.
3. Mounsey, Anne L; Matthew, Leah G; Slawson, David C. Herpes Zooster and Postherpetic Neuralgia: Prevention and Management. American Family Physician: September 15, 2005. Volume 72 Number 6
4. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare 2016:9 447-454
@sukedanapt
Sumber: Obata, Hide
aki. Analgesic Mechan
isms of Antidepressan
ts for Neuropathic Pai
n. Internationa Journal
of Molecular Science
s. 2017,18, 2483
@sukedanapt
Anticonvulsants
 Gabapentin: dose started 300-600 mg orally three times per
day1 Taper dose over seven days when discontinuing therapy,
Gabapentin & Maximum dose 3.600 mg/day2
Pregabalin  Adverse effect: Dizziness, peripheral edema, sedation, weight
gain, dry mouth, constipation1,2
 Pregabalin: dose started 150-300 mg orally per day in two or
three divided doses. Maximum dose 600 mg.day. Adverse
effect same like Gabapentin1,2
 Mechanism through calcium chanel 2-ligands voltage-gated calcium channel blockers, inhibiting central pain pathways
2: 3
 In the Cochrane Database of Systematic Reviews, the NNT to obtain a patient with a 50 % reduction in pain was 7.5 for
gabapentin and 5.0–11 for pregabalin 300–600 mg3
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2. Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare
2016:9 447-454
@sukedanapt
Hayashida, Ken-ichiro; Obata, Hideaki. Strategies to Treat Chronic Pain and Strengthen Impaired Descening Noradrenergic Inhibitory System. International Journal of Molecular
Sciences. 2018, 20, 822
Fentanyl • Apply at skin and replace every 3 days. Popular because
avoid needles. Reduced side effect compare morphine1
Patch
• Lidocaine blocks voltage-gated sodium

channels3 Lidocaine 5% patches has
Lidocaine been shown both in clinical practice and
improved quality of life and 66% reduced
5% Patch pain2. NNT 2.0-4.43
• Apply every 4-12 hours, up to three
patches per day2
1.
1. Gwinnutt,
Gwinnutt, Carl
Carl L.
L. 2004.
2004. Lecture
Lecture Notes
Notes Clinical
Clinical Anaesthesia.
Anaesthesia. Second
Second Edition.
Edition. UK:
UK: Blackwell
Blackwell Publishing
Publishing
@sukedanapt
2.
2. Searle,
Searle, Theresa
Theresa Mallick;
Mallick; Snodgrass,
Snodgrass, Brett;
Brett; Brant,
Brant, Jeannine
Jeannine M.
M. Postherpetic
Postherpetic neuralgia:
neuralgia: epidemiology,
epidemiology, pathophysiology,
pathophysiology, and
and pain
pain management
management pharmacology.
pharmacology. Journal
Journal of
of Multidiciplinary
Multidiciplinary
Healthcare
Healthcare 2016:9
2016:9 447-454
447-454
3.
3. Nalamachu,
Nalamachu, Srinivas;
Srinivas; Forster,
Forster, Patricia
Patricia Morley.
Morley. Diagnosis
Diagnosis and
and Managing
Managing Postherpetic
Postherpetic Neuralgia.
Neuralgia. Drugs
Drugs Aging.
Aging. 2012;
2012; 29(11):
29(11): 863–869
863–869
• Tramadol provided significant pain relief in patients with PHN
OPIOD
Tramado (NNT 4-5)1 Starting dose at 50 mg one or two times per day;
titrated in 50-100 mg increments in devided doses every 3-7
l days. Maximum dosage 400 mg/day2 Adverse reactions:

Dizziness, nausea, constipation, headache, somnolen,
flushing, pruritus, vomiting, insomnia, dry mouth, diarrhea,
sweating, anorexia, postural hypotension
• Commonly used (oral/IV). Dose:10-
Morphine 15 mg every 4 hours. Side effect:

Sedation, but can minimalize by
titration2,3 NNT 2.74
2.
3.
4.
Searle, Theresa Mallick; Snodgrass, Brett; Brant, Jeannine M. Postherpetic neuralgia: epidemiology, pathophysiology, and pain management pharmacology. Journal of Multidiciplinary Healthcare 2016:9 447-454
Gwinnutt, Carl L. 2004. Lecture Notes Clinical Anaesthesia. Second Edition. UK: Blackwell Publishing
Nalamachu, Srinivas; Forster, Patricia Morley. Diagnosis and Managing Postherpetic Neuralgia. Drugs Aging. 2012; 29(11): 863–869
@sukedanapt
Combination Therapy
First Option
Lidocaine 5 % topical patch in combination
with systemic agent such as pregabalin 1
Second Option
Systemic agents combinations such as
gabapentin/nortriptyline or
morphine/gabapentin1
@sukedanapt
Thank you
 Almighty God
 Dedication to: Alm Wayan Budiarsana, my family for their support
 My teachers from elementary until medical faculty
 My senior who share their experienced to treat patients with PHN
 This slides still needs to be improved. If there is any input/opinion, we are welcome
with that

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Treatment For Chronic Pain: (Postherpetic Neuralgia/PHN)

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Treatment for Chronic Pain

Our home until 2017 -

- Our dreams comes true 2018

2 Epidemiology Postherpetic Neuralgia/PHN

 Pain in a dermatomal distribution that is sustained for at least 90 days after t

After the primary VZV infection (chickenpox),

The trigeminal and thoracic ganglia are the

First Line: Tricyclic antidepressant, Nerve block, Stimulation,

 Available as tablet 10,25,50  Dose started12,5-25 mg

• Lidocaine blocks voltage-gated sodium

l days. Maximum dosage 400 mg/day2 Adverse reactions:

• Commonly used (oral/IV). Dose:10-

Morphine 15 mg every 4 hours. Side effect:

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