Wim Opstelten

Background. The main complications of herpes zoster (HZ) are postherpetic neuralgia and, in case of HZ ophthalmicus, eye disorders. Antiviral treatment may modify the course of disease and reduce the risk of complications. Objective. To assess which doctors' and patients' characteristics were related to prescription of antiviral therapy for HZ. Methods. Ninety general practices (358 008 patients) in The Netherlands registered all patient contacts in a database for one year as part of the Second Dutch National Survey of General Practice. The present study used ICPC code S70 to search that database for patients with a new diagnosis of HZ. The full-text medical records of the selected patients were then reviewed and the potential determinants for the prescription of antiviral drugs (including characteristics of patients, GPs, and practices) analysed using multilevel logistic regression modelling. Results. Of the 1129 patients diagnosed with HZ (incidence 3.2/1000 patients/year), 22.5% received antiviral drugs. Independent determinants for prescription of antiviral therapy were age [45–54 years: adjusted odds ratio (OR) 2.9 (95% CI 1.6–5.0); 55–64 years: OR 4.2 (95% CI 2.4–7.6); 65–74 years: OR 5.1 (95% CI 2.7–9.6); ≥75 years: OR 8.1 (95% CI 4.4–15.1)], ophthalmic localisation of the shingles (OR 3.2, 95% CI 1.6–6.7), and the presence of asthma/COPD (OR 1.6, 95% CI 1.0–2.6). GPs who reported to strongly adhere to professional guidelines prescribe more frequently antiviral drugs (OR 1.9, 95% CI 1.2–3.1). Conclusions. A minority of HZ patients were prescribed antiviral treatment. Increasing age, ophthalmic localisation, presence of asthma/COPD, and adherence to professional guidelines were factors favouring prescription. More information on the determinants of GPs' treatment decisions is necessary for successful implementation of HZ guidelines.

Postherpetic neuralgia (PHN) is by far the most common complication of herpes zoster (HZ) and one of the most intractable pain disorders. Since PHN is seen most often in the elderly, the number of patients with this disorder is expected to increase in our ageing society. PHN may last for months to years and has a high impact on the quality of life. The results of PHN treatment are rather disappointing. Epidural injection of local anaesthetics and steroids in the acute phase of HZ is a promising therapy for the prevention of PHN. Since randomised trials on the effectiveness of this intervention are lacking, the PINE (Prevention by epidural Injection of postherpetic Neuralgia in the Elderly) study was set up. The PINE study compares the effectiveness and cost-effectiveness of a single epidural injection of local anaesthetics and steroids during the acute phase of HZ with that of care-as-usual (i.e. antivirals and analgesics) in preventing PHN in elderly patients. The PINE study is an open, multicenter clinical trial in which 550 elderly (age ≥ 50 yr.) patients who consult their general practitioner in the acute phase of HZ (rash < 7 days) are randomised to one of the treatment groups. The primary clinical endpoint is the presence of HZ-related pain one month after the onset of the rash. Secondary endpoints include duration and severity of pain, re-interventions aiming to treat the existing pain, side effects, quality of life, and cost-effectiveness. The PINE study is aimed to quantify the (cost-) effectiveness of a single epidural injection during the acute phase of HZ on the prevention of PHN.

Background. Postherpetic neuralgia (PHN) is a frequent complication of herpes zoster (HZ). Treatment results of this severe and long-lasting pain syndrome are often disappointing. From the point of view of possible prevention and early treatment, it is important to identify HZ patients who have an increased risk of developing PHN. Objectives. Our goals were to determine the incidence of HZ and PHN in a primary care population and to identify risk indicators for the occurrence of PHN. Methods. A search for HZ and PHN was conducted in a general practice research database, comprising 22 general practices and representing 49 000 people, over a 5-year period. Potential risk indicators were analysed using multivariate logistic regression. Results. A total of 837 patients had been diagnosed with HZ [incidence 3.4/1000 patients/year, 95% confidence interval (CI) 2.9–3.9]. The risk of developing PHN 1 month after the start of the zoster rash was 6.5% (95% CI 4.9–8.3). This risk was 11.7% (95% CI 8.5–14.9) for patients aged ≥55 years. Independent risk indicators for the occurrence of PHN were age [55–74 years, adjusted odds ratio (OR) 4.2, 95% CI 1.8–9.7; >75 years, OR 10.7, 95% CI 4.6–25.1] and ophthalmic localization (OR 2.3, 95% CI 1.0–4.6). Conclusions. The risk of developing PHN increases with age. Preventive strategies should focus on patients with herpes zoster aged >55 years and with ophthalmic localization.