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Note: reversal of conclusion
This reverses the Level 1 conclusion in the previous edition of this
document; earlier meta‐analyses reported a reduced incidence of
PHN.
Similarly, systemic corticosteroids (He et al, 2008 Level I) or an epidural injection with
methylprednisolone and bupivacaine (van Wijck et al, 2006 Level II) were ineffective preventive
strategies.
In the review by Kumar et al (Kumar, Krone et al, 2004) five of eight studies (63%) looked at
prevention of PNH (one RCT only) and suggested that neuraxial blockade during HZ reduced
the incidence of PHN at 6 months. The RCT found that local anaesthetic and steroid injections
via an epidural catheter, for up to 21 days during HZ, significantly reduced the incidence (but
not the intensity) of pain for 1 to 6 months, compared with systemic antiviral therapy plus
prednisolone; however such an approach has limited practical application (Pasqualucci et al,
2000 Level II).
Key messages
1. Antiviral agents started within 72 hours of onset of the herpes zoster rash accelerate the
resolution of acute pain (U) (Level I), but do not reduce the incidence of postherpetic
neuralgia (R) (Level I) [Cochrane Review]).
2. Immunisation of persons aged 60 years or older with varicella‐zoster virus vaccine reduces
the incidence of herpes zoster and postherpetic neuralgia (N) (Level II).
3. Amitriptyline (used in low doses for 90 days from onset of the herpes zoster rash) reduces
the incidence of postherpetic neuralgia (U) (Level II).
4. Topical aspirin, topical lignocaine patch or oxycodone controlled release, provide analgesia
in herpes zoster (N) (Level II).
The following tick box represents conclusions based on clinical experience and expert
opinion.
Provision of early and appropriate analgesia is an important component of the
management of herpes zoster and may have benefits in reducing the incidence of
postherpetic neuralgia. CHAPTER 9
9.6.3 Acute cardiac pain
Acute coronary syndrome refers to a range of acute myocardial ischaemic states including
unstable angina and myocardial infarction. Typically, myocardial ischaemia causes central
chest pain, which may radiate into the arm, neck or jaw; non‐typical presentations can occur,
particularly in the elderly patient (see Section 11.2). Reducing ischaemia by optimising
myocardial oxygen delivery, reducing myocardial oxygen consumption and restoring coronary
blood flow will reduce ischaemic pain and limit myocardial tissue damage. The mainstay of
analgesia in acute coronary syndrome is the restoration of adequate myocardial oxygenation
as outlined above, including the use of supplemental oxygen (Pollack & Braunwald, 2008;
Cannon, 2008).
Nitroglycerine was effective in relieving acute ischaemic chest pain; however, the analgesic
response did not predict the diagnosis of coronary artery disease (Henrikson et al, 2003 Level IV).
In patients with suspected acute coronary syndrome, IV morphine significantly reduced pain
within 20 minutes of administration; morphine doses were low (average of 7 mg over 3 days)
Acute pain management: scientific evidence 255
