Shingles and Lung Cancer - 1261722

hain
Posts:113

Hello everyone,

I just wanted to ask a question in regards to management of severe pain from shingles. My mom has Stage IV adenocarcinoma with mets to her rib and vertebrae. She has been on Gefitinib (Iressa) since June 2013 and has been doing great.

A couple of days ago, my mom went to the emergency room at her hospital due to severe sharp pain felt on her right upper back that persisted for 2 days despite being on Tylenol 2's. She was diagnosed with shingles and was given an anti-viral med called Valtrex 500 taken 3 times per day for 7 days, and percocets for pain.

Without the percocets she describes her pain as feeling like she just got out of surgery which can be very painful, she cried a couple of times due to the pain, which is saying a lot since she normally doesn't complain of much pain even after her lobectomy several years ago.

My questions are:

1. She requires 1 percocet every 3.5-4 hours to keep the pain at bay (the emergency doctor prescribed 1-2 tablets every 6 hours as needed). Is there any concerns with long term continuous use (I know the acetaminophen could have effects on the liver if taken in high dosases beyond 4grams)? And should she be on a stool softener despite having regular bowel movements although her stool is harder than usual?

2. Could she benefit from topical creams (such as ones containing lidocaine) to help with her pain, so she is not as dependent on her percocets? Placing an ice pack over her back seems to help temporarily.

If anyone has any other recommendations in terms of management and advice on reducing chances of long term posttherpetic neuralgia would be very much beneficial!

Sorry for the long winded questions and thanks in advance for the replies!

Best regards,
Will

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Reply # - January 24, 2014, 02:17 PM

JimC
Posts: 2753

Hi Will,

Long-term use of high daily doses of acetaminophen is certainly a concern, and even the limit of 4g per day has come into question as too high. You may want to talk to her doctor about alternatives. Dr. West has previously said that "The pain of shingles is notoriously severe, and it's a type called neuropathic pain. This may sometimes be treated effectively by drugs like lyrica (pregabalin) or neurontin (gabapentin)." - http://cancergrace.org/forums/index.php?topic=1049.msg5382#msg5382

Constipation is often an issue with the use of narcotics, and it is one that is better controlled by staying ahead of it (harder to get rid of than to prevent), so if her stools are getting harder, a stool softener is probably a good idea.

Patches and topical creams can be used to control shingles pain, so that is another matter which should be discussed with her doctor.

Good luck in helping your mom manage her pain.

JimC
Forum moderator

Reply # - January 24, 2014, 06:29 PM

Dr West
Posts: 4735

I don't have much to add here, except that it would be very reasonable to request an opioid pain medication that doesn't include Tylenol, such as garden variety morphine or oxycodone, etc. -- there wouldn't be a concern about liver or kidney damage, but constipation could always be an issue. And because these all lead to constipation, I favor a very low threshold for using stool softeners or laxatives in patients on such medications.

Good luck.

-Dr. West

Reply # - January 24, 2014, 07:44 PM

hain
Posts: 113

Thank you Jim and Dr. West!

We'll talk to my mom's doctor and see if she can switch to oxycodone instead of percocets. We'll also pick up some stool softener at the pharmacy tomorrow.

Just wondering if it would help to reduce morbidity and if it is conventional if my mom used Zovirax ointment concurrently with her Valtrex 500? Zovirax ointment was recommended by a relative who was prescribed it when she had shingles long ago.

Best regards,
Will

Reply # - January 25, 2014, 10:55 AM

double trouble
Posts: 573

Dear Will,

I am sorry to learn that you and your Mom are dealing with so much. I don't know anything about shingles, but I am on oxycodone, and have to maintain a very strict regimen to prevent constipation. I take miralax at night and am about to add a senna s stool softener. The miralax is a powder that you can mix with any liquid. It is tasteless, and does not cause any unpleasant side effects such as gas or abdominal cramps. You might want to ask her physicians if that would be an option.

Much love,
Debra

Reply # - January 25, 2014, 11:06 AM

double trouble
Posts: 573

Hi again,

I just wanted to add that as Jim suggested, Lyrica or Gabapentin works wonders for nerve pain. I started on Gabapentin, had side effects I didn't care to tolerate, switched to Lyrica, and have been on it ever since. We occasionally increase the dosage as needed.

Also, as (technically) a stage 4, I have found that my team does not want me in pain. I'm sure you will have no trouble getter her pain under control. You just have to let them know what is happening.

Much love,
Debra

Reply # - January 25, 2014, 12:35 PM

hain
Posts: 113

Hello Debra,

Thanks for your words of wisdom. My mom is a warrior and is enduring the pain; with the help of her meds of course. My only concern is that the shingles infection is weakening her immune system which may predispose her to further metastatic disease (*crosses finger*).

Just got back from pharmacy and picked up a bottle of Senokot S, which contains docusate sodium 50mg (laxative) and sennosides 8.6mg (stool softener) all in one pill - hope it helps.

I'll keep those meds in mind when asking the doctor on Monday regarding refilling her pain meds.

Still have a question for Dr. West or any other health professionals in terms of advice on whether Zovirax ointment may be beneficial in addition to her anti-viral pills (Valtrex 500).

Best,
Will

Reply # - January 25, 2014, 12:55 PM

double trouble
Posts: 573

Hi again Will. I'm sure Janine or Jim (moderators) will pass the question along to Dr. West. It's a weekend so response may be a bit slower.

Debra

Reply # - January 25, 2014, 01:26 PM

Dr West
Posts: 4735

I haven't prescribed or seen topical antiviral cream like Zovirax used for shingles because the area affected is so great, and the cream is really used for a small discrete lesion like a cold sore, not for a large area of skin with crops of blistering lesions. Other docs may have experience with topical creams for shingles/zoster infections, but I think it wouldn't be a common recommendation.

Good luck.

-Dr. West

Reply # - January 27, 2014, 04:54 PM

hain
Posts: 113

Hello Dr. West,

My mom received repeats for percocets today. We couldn't ask the doctor for oxycodone or anything without acetaminophen since the nurse didn't want to bother the doctor with the request, which is fine, since we were told by a pharmacist that long term (around 1 year) of acetaminophen usage may cause liver damage not in the short term as is probably required for my mom.

My question is in regards to another medication that the doctor prescribed called Gabapentin, 300 mg to be taken nightly, starting tonight. The nurse mentioned that this medication is used to prevent long term shingles pain and the pharmacist mentioned that this medication is used to specifically aid in nerve regeneration from shingles, not only for pain. Maybe my searching skills are poor, but the only information I was able to find on Gabapentin and shingles was that it is used to control pain, with no mention to aiding in neural regeneration. Hence, I was wondering if you could comment on this? My only concern is that my mom's pain seems to be improving and is currently being adaquately controlled by the percocets (the prescribing doctor is unaware of this peice of information as I was only able to speak to the nurse on the phone); hence, if this med is only indicated for pain then it seems redundant and unnecessary. We are trying to minimize my mom from taking too many meds if not necessary as she currently experiences side effects from her current meds (e.g. dizziness and nausea from Valtrex 500 and percocets).

Hoping you could provide comment on this medication and looking forward to your reply. Sorry for the long read!

Best regards,
Will

Reply # - January 27, 2014, 08:11 PM

Dr West
Posts: 4735

Gabapentin is commonly prescribed, I think more for the pain control than for any proven benefit for neural regeneration. You can see from several of the responders above that they had taken and mentioned gabapentin as an option. Your doctor is really the person who should discuss whether to take it in addition to or preferentially to Vicodin.

-Dr. West

Reply # - May 10, 2014, 10:16 AM

hain
Posts: 113

Dear Dr. West,

For the past couple of days my mom has had the same intermittent sharp pain that comes and goes on her right upper back/thoracic region. It is in the same region that she felt the pain 3 months ago when she was diagnosed with shingles.

Although she is currently experiencing similar pain (although a bit milder, 6-8/10 intermittent), there is currently no rash or any skin lesions that are obvious to indicate that shingles is present. We are just wondering if you believe that my mom should obtain follow up? Also, should she ask for anti-viral meds right now at first sign of possible shingles recurrence? Or should she wait for the skin lesions to appear before taking anti-viral meds to be sure? My mom was prescribed Valtrex 500, for 7 days back in January this year, do you think she would benefit from taking another dose for this episode or should she just stick to pain meds?

Other than this episode, my mom is currently stable and continuing to respond to Iressa once daily.

Hope to hear from you or anyone who might have an answer.

Thank you,
Will

Reply # - May 10, 2014, 10:58 AM

JimC
Posts: 2753

Hi Will,

Any time a patient is experiencing new pain, it's a good idea to report it to her doctor. Beyond that, the kind of "What should I do?" questions are beyond the legal and practical scope of what the GRACE faculty can do. Her own doctors, who know all of her medical history and have an opportunity to examine her, are best equipped to make those decisions.

I'm hoping that because the pain is in the same place as it was previously and is intermittent (not typical of cancer pain), this is something that can be controlled with pain meds and/or anti-virals.

JimC
Forum moderator

Reply # - May 10, 2014, 11:20 AM

hain
Posts: 113

Hi Jim,

Thanks for your reply! Just to give a little more context to my question:

Last night my mom and I was in the ER because she was in a lot of pain so we wanted to get her examined and possibly ask for a prescription for anti-virals if she indeed has recurrence of her shingles. We waited for a couple hours but it was getting very late and seemed like the line wasn't moving so we decided to head home and visit my mom's family doctor the next morning. She took an oxycocet for her pain last night (she had some left from her last episode in January).

This morning her family doctor, who I should add has extremely bad bedside manners, dismissed her concerns, did not physically examine her, and just said that its probably shingles, and gave her a prescription for Lyrica (for nerve pain). She asked about possibly taking anti-virals to reduce the episode of pain and severity, but the doctor replied that those meds can only be taken once in a lifetime, so he will not prescribe it (Valtrex 500). This was not the same doctor who prescribed her the anti-virals as it was an ER doctor who prescribed it for my mom back in January.

So now we are confused with whether or not it would be worth it to pay another visit to the ER and see another doctor who would actually examine my mom and appropriately diagnose her, or should we just wait it out and report the new symptoms to my mom's onc on Monday who might tell her to go see her family doctor, whom we already have seen this morning.

I understand that doctor's from Grace can not answer the "should I" questions, but I just wanted to see what the usual course of actions are to see our options and to make a more informed decision. For example, are anti-virals normally prescribed for a recurrent episode of shingles, or are recurrences treated with only pain meds?

Thank you,
Will

Reply # - May 10, 2014, 12:02 PM

JimC
Posts: 2753

Hi Will,

Here's what the Mayo Clinic has to say about recurrent shingles:

"Reactivation of varicella-zoster virus and resultant shingles happens when your immune system is weakened by medications such as cancer treatments, steroids or simply by aging.
...
Although people with weakened immune systems are at highest risk for developing shingles, the vaccine, unfortunately, is often not an option for them, as it is a live vaccine and hence not safe for people with weakened immune systems.

If you cannot receive the shingles vaccine, the best option for dealing with recurrent shingles is to treat each episode with prescription antiviral medication and pain medication as soon as possible. If you take antivirals within 48 hours of the rash appearing, the chances that you will develop postherpetic neuralgia are much lower. Your rash will also heal faster, and there will be less scarring and less pain associated with the rash.

If your immunosuppression is severe and the shingles episodes are frequent, talk to your doctor about the possibility of taking antiviral medication daily for a time. In some cases, this may help suppress subsequent episodes of shingles." - http://newsnetwork.mayoclinic.org/discussion/early-treatment-often-the-…

JimC
Forum moderator

Reply # - May 11, 2014, 08:34 AM

hain
Posts: 113

Thanks Jim for the reply and providing a reference. I've seen this article also, which lead to my confusion as it provided conflicting information from what the family medical doctor was saying. Specifically, the article mentions that each episode of shingles should be treated with anti-virals and pain medications. However, the family doctor only prescribed Lyrica and mentioned that anti-virals can only be taken once in a lifetime, which is why I decided to ask Dr. West or other physicians on this site to see what their opinions are on the matter.

It seems like my mom's condition is better, she doesn't have as much pain and doesn't have the sharp pain any longer. Still there is no signs of any skin lesions. Having said that, I'm not sure if the cause of her symptoms are from shingles or some other cause. If it is from shingles, is it generally recommended that patients typically receive anti-virals despite not having any signs of skin lesions?

Reply # - May 11, 2014, 10:29 AM

Dr West
Posts: 4735

Anti-virals are generally not pursued when there is no evidence of the skin lesions. To my knowledge, there is no evidence saying thta there should be a restriction to one course of anti-viral therapy if pateints have multiple outbreaks. However, it is important to note that we offer insights on the current optimal treatment for cancer, but we don't mean to claim that we are infectious disease experts.

-Dr. West

Reply # - May 12, 2014, 07:25 PM

hain
Posts: 113

Thank you Dr. West for your reply.

I'm just really curious if its common or even possible for a person to experience a shingles episode that only includes sharp intermittent pain that lasts for several days (4 to be exact) and then completely resolves, without showing any signs of skin lesions.

Although my mom's condition has completely resolved, I'm also just really curious to what this could possibly be if its not shingles and whether or not it is related to my mom's metastatic lung cancer disease. For example, could it be from a diet that is high in seafood, so high in mercury, which may adversely affect the nerves?

Thank you,
Will

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