Treatment of Shingles in Immunocompromised Patients

Immediate Treatment Recommendation

• Immunocompromised patients with shingles require high-dose intravenous acyclovir (10 mg/kg every 8 hours) as the treatment of choice, with consideration for temporary reduction of immunosuppressive medications in severe or disseminated cases 1, 2, 3

Treatment Algorithm Based on Disease Severity

• For mild cases with transient immunosuppression, the Infectious Diseases Society of America recommends oral valacyclovir 1000 mg three times daily for 7-10 days OR oral acyclovir 800 mg five times daily for 7-10 days 1, 2, 3
• The American College of Gastroenterology suggests continuing treatment until all lesions have completely scabbed, not just for an arbitrary 7-day period 2, 3

Indications for IV Therapy

• The Centers for Disease Control and Prevention indicate that multi-dermatomal involvement (≥2 dermatomes) requires IV therapy 2
• Visceral dissemination (hepatitis, pneumonitis, encephalitis) also necessitates IV therapy, according to the Infectious Diseases Society of America 1

Management of Immunosuppressive Medications

• The European Crohn’s and Colitis Organisation recommends temporarily discontinuing or reducing immunosuppressive therapy in cases of disseminated or invasive VZV infection 4, 2, 3

Special Considerations for Specific Immunocompromised Populations

• The American Society of Transplantation suggests that kidney transplant recipients with uncomplicated herpes zoster should receive oral acyclovir or valacyclovir at standard doses 2
• Allogeneic blood and bone marrow transplant recipients should take acyclovir 800 mg twice daily or valacyclovir 500 mg twice daily during the first year post-transplant for prevention, as recommended by the Infectious Diseases Society of America 1

Duration of Therapy

• The Infectious Diseases Society of America recommends a minimum 7-10 days of treatment for all immunocompromised patients 2, 3
• Treatment should continue until all lesions have completely scabbed, which is the key clinical endpoint, not calendar days 2, 3

Monitoring During Treatment

• The Centers for Disease Control and Prevention suggest monitoring renal function closely during IV acyclovir therapy with dose adjustments for renal impairment 2
• The American College of Gastroenterology recommends assessing for cessation of new lesion formation within 48-72 hours of starting therapy 1

Acyclovir Resistance

• The Infectious Diseases Society of America indicates that acyclovir-resistant strains have been isolated from immunocompromised patients, particularly those on long-term suppressive therapy 1, 5
• For acyclovir-resistant VZV, the Centers for Disease Control and Prevention recommend foscarnet 40 mg/kg IV every 8 hours as the alternative treatment 3

Post-Exposure Prophylaxis for Susceptible Patients

• Varicella-susceptible immunocompromised patients exposed to active VZV should receive varicella zoster immunoglobulin (VZIG) or IVIG within 96 hours of exposure, according to the Infectious Diseases Society of America 2, 3

Prevention Strategies

• The European Crohn’s and Colitis Organisation recommends screening all immunocompromised patients for VZV immunity at diagnosis 4
• Seronegative patients should receive two doses of varicella vaccine at least 3 weeks before starting immunosuppressive therapy, as suggested by the American College of Gastroenterology 4