NEURALGIA POSHERPÉTICA
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Transcript of NEURALGIA POSHERPÉTICA
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NEURALGIA NEURALGIA POSHERPÉTICAPOSHERPÉTICA
ERWIN ASPRILLARI ANESTESIOLOGIA
UMNG – HOMIC2010
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NPH: 3ra causa de dolor NPH: 3ra causa de dolor neuropaticoneuropatico
The impact of varicella zoster virus: Chronic painJournal of Clinical Virology 48 (2010) S1, S8–S13
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Problema de Salud Problema de Salud Publica ???Publica ???
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NEURALGIA NEURALGIA POSTHERPETICAPOSTHERPETICA
Dolor luego de la finalización del exantema (90 a 120 días).
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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EPIDEMIOLOGIAEPIDEMIOLOGIA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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EPIDEMIOLOGIAEPIDEMIOLOGIA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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EPIDEMIOLOGIAEPIDEMIOLOGIA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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EPIDEMIOLOGIAEPIDEMIOLOGIA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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ETIOLOGIAETIOLOGIA
DNA VIRUS Alfaherpesviridae Varicellovirus
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ETIOLOGIAETIOLOGIADiámetro de 150 a 200 nm, 125000 pares de
bases, 2 cadenas DNA isomericas que codifica 70 productos génicos.
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ETIOLOGIAETIOLOGIA
Advances in the understanding of the pathogenesis and epidemiology of herpes zosterJournal of Clinical Virology 48 (2010) S1, S2–S7
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ETIOLOGIAETIOLOGIA
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Complicaciones de la Complicaciones de la Infeccion HZInfeccion HZ
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PRINCIPAL FACTOR DE PRINCIPAL FACTOR DE RIESGORIESGO
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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FACTORES DE RIESGOFACTORES DE RIESGO
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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POBLACIONES POBLACIONES SUCEPTIBLESSUCEPTIBLES
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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F.R. NEURALGIA POST F.R. NEURALGIA POST HERPETICAHERPETICA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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CARACTERISTICAS CARACTERISTICAS CLINICASCLINICAS
Reactivación del VVZ Diseminación al ganglio sensorial y al
nervio periférico .Activación de la R// inmune.Inflamación y destrucción neuronal
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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FISIOPATOLOGIAFISIOPATOLOGIA
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HISTORIA NATURALHISTORIA NATURAL
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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FASES DEL DOLORFASES DEL DOLOR
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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CARACTERÍSTICAS DEL CARACTERÍSTICAS DEL DOLORDOLOR
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MECANISMOS DEL MECANISMOS DEL DOLORDOLOR
Dolor preherpetico Alodinia - Hiperalgesia
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DOLOR CRONICODOLOR CRONICO
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SUBTIPOSSUBTIPOS
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SUBTIPOSSUBTIPOS
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Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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COMPROMISO OCULARCOMPROMISO OCULARVHZ: Rama oftálmica del
trigémino 10 – 15%Complicaciones oculares > si lesión
nasociliarCompromiso corneal y de la uvea:
◦Anestesia, ulceración corneal, glaucoma, neuritis óptica, ceguera.
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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OTRAS COMPLICACIONES OTRAS COMPLICACIONES VHZVHZACV 2ria a Arteritis granulomatosa
de la Carótida interna.Paresia focal motoraParálisis facialSíndrome de Ramsay Hunt
(hipoacusia vértigo y parálisis facial)
Meningoencefalitis MielitisInfección bacteriana 2ria.
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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ValoracionValoracion The presence of prodromal pain can be assessed by asking, “Did you have any pain before the rash appeared in the area where you now have your shingles rash?” The presence of herpes zoster pain can be assessed by asking, “Do you have any pain in the area where you now have your shingles rash?” And the presence of pain after rash healing can be assessed by asking, “Do you have any pain in the area where you had your shingles rash?” Although such assessments of the presence of any pain are a necessary first step in evaluating herpes zoster pain and PHN, they must be supplemented by assessments of pain intensity, as discussed below.
Diagnosis and Assessment of Pain Associated With Herpes Zoster and Postherpetic Neuralgia. The Journal of Pain, Vol 9, No 1 (January), Supplement 1, 2008: pp S37-S44
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DIAGNOSTICODIAGNOSTICOCLINICA≠ de la infección por Herpes
simple.Otras condiciones:
◦Dermatitis de contacto, quemaduras, lesiones fúngicas.
Presentaciones atípicas◦Cultivo viral, IFI, PCR, Serología.
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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TratamientoTratamiento
www.thelancet.com Vol 367 January 21, 2006
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TRATAMIENTO INFECCIÓN TRATAMIENTO INFECCIÓN AGUDAAGUDA
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
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TERAPIA ANTIVIRALTERAPIA ANTIVIRAL
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No hay diferencias en la incidencia de NPH
Famciclovir
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NEURITIS POR HERPES NEURITIS POR HERPES ZOSTERZOSTERCORTICOESTEROIDES
Poca evidencia que combinados con antivirales aceleren la tasa de cicatrización
No protegen contra la NPHÚnica indicación la NHZ oftálmica
ANALGESICOSAINES (proceso inflamatorio)OPIOIDES
◦Tramadol e Hidrocodona◦Rotar con Morfina u Oxicodona
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TERAPIA ADYUVANTETERAPIA ADYUVANTE
Herpes Zoster and Postherpetic Neuralgia in Older Adults Kenneth Schmader, .Clin Geriatr Med 23 (2007) 615–632
Ninguno ha demostrado prevenir la incidencia de neuralgia posherpetica, pero pueden ser útiles para ↓ el dolor agudo
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NEURALGIA POST NEURALGIA POST HERPETICA HERPETICA
Evaluación y manejo multidisciplinarioIniciar con terapias poco invasivas
para pasar a tratamientos mas agresivos.
TRATAMIENTO EN FUNCION DEIntensidad del DolorEdad del pacientePatologías AsociadasResultados de tratamientos previos
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NEURALGIA NEURALGIA POSHERPÉTICAPOSHERPÉTICA
Terapias de primera línea↓ el dolor en 30 a 60% de los pacientes
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OPIOIDESOPIOIDES
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OPIOIDESOPIOIDESOXICODONA:
◦ NNT: 2,5, DISMINUCION VAS DE UN 50%◦ NNH: 38
MORFINA◦ NO MORFINA EPIDURAL / CLASE IV
TRAMADOL◦ REDUCCION > 50% DEL DOLOR NNT: 4.7
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ANTIDEPRESIVOS ANTIDEPRESIVOS TRICICLICOSTRICICLICOS
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ANTICONVULSIVANTESANTICONVULSIVANTES
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Dos Estudios
NNT: 3.9 (95% CI 3 -5.7)RR: 2.5 (95% CI 1.8 to
3.3)
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PregabalinaPregabalina
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TOPICOSTOPICOS
Lidocaína gel al 5%Control rápido de la alodinia Efectos colaterales nulos8h después de aplicación4 horas después de remociónClase I
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CapsaicinaCapsaicina
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CAPSAICINA
◦NNT: 5.3◦REDUCCIÓN EN VAS◦DISMINUCION VAS 23% DESPUES DE
4 SEMANAS
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OTROSOTROSANTAGONISTAS NMDA:
◦ KETAMINA◦ NO MEJORIA RESPECTO A PLACEBO
METILPREDNISOLONA
◦ INTRATECAL ↓ IL 8◦ NNT: 1,3◦ EVENTOS ADVERSOS : ARACNOIDITIS◦ EFECTIVA EN DISMINUCION DE NPH◦ CLASE I - IIA
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The evidence for pharmacological treatment of neuropathic painNanna Brix Finnerup a,*, Søren Hein Sindrup b, Troels Staehelin Jensen a
PAIN 150 (2010) 573–581
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Manejo Intervencionista Manejo Intervencionista NPHNPH"Estoy tan convencido de la
eficacia del bloqueo neuroaxial que tuve que realizarlo, como el único tratamiento para mi propio caso de HZ el de mi esposa y uno de mis hermanos”
Bonica
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Interventions to prevent postherpetic neuralgia: cutaneous and percutaneous techniquesPain 107 (2004) 202–206
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•277 pacientes con NPH de más de un año•LIDOCAINA 3% (3CC) + METILPREDNISOLONA 60 MG (n 89) vs LIDOCAINA 3% (3CC) (n 90)•C/sem x 1 mes•Evaluación del dolor 4 sem, 1 año y 2 años•Muestras de LCR il 8 antes y después•Lidocaína + metilprednisolona efectiva ↓ il8 en 50%•La [ ] il 8 se correlacionó inversamente con la persistencia de NPH p<0.001
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A pesar de los prometedores resultados de este estudio, los esteroides por vía intratecal no han llegado a ser ampliamente utilizada en la NPH, debido principalmente a las preocupaciones sobre la seguridad y la falta de confirmación o verificación en la práctica clínica
Management of herpes zoster and post-herpetic neuralgia now and in the future
Richard J. Whitleya, *, Antonio Volpib, Mike McKendrickc, Albert van Wijckd, Anne Louise Oaklandere
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USO DE LA VACUNA ◦ ↓ 61% magnitud◦ ↓ 51% incidencia de HZ◦ ↓ 66.5 Neurlagia posherpetica◦ RX adversas: inflamacion en aplicación ◦ Duración de la protección?
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SINTESIS DE LA EVIDENCIA
BUSQUEDA DE BASE DE DATOS: 1966 A 2001
21 ENSAYOS CLINICOS- DOLOR AGUDOS: 71%- NPH: 29%- NIVEL EVIDENCIA I: 20%
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80% MOSTRARON RESULTADOS POSITIVOS
EFECTO BENEFICIOSO DE PERIDURAL CON ESTEROIDES EN NPH Y HZ
EPIDURAL CON CORTICIDES DENTRO DE LOS DOS PRIMEROS MESES: REDUCE LA INCIDENCIA DE NPH HASTA UN AÑO GRADO A
EFECTO BENEFICIOSO DE INTRATECAL CON ESTEROIDES EN NPH GRADO A
BLOQUEO SIMPATICO: PODRIA SER UTIL GII B PERO FALTA MEJOR EVIDENCIA.
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EFICACIA DESCONOCIDA DEL METODO.
ENSAYO CLINCIO
METODOS: RECIBIERON NEUROESTIMULADORES IMPLANTABLES EN RAMAS DE V1 Y V2
RAMAS SUPRAORIBITARIA E INFRAORBITARIA
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EVALUACION- MEJORIA DEL DOLOR- USO DE ANALGESICOS- DURACION DE LA MEJORIA- EFECTOS ADEVERSOS
SE PRODUJO HASTA UN 50% DE MEJORIA EN 70% DE LOS PACIENTES
SATISFACCION DEL 80%
REDUCCION DEL 70% DE ANALGESICOS
NO FALLAS DEL TRATAMIENTO
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ESTUDIO PROSPECTIVO EN 28 PACIENTES CON NPH
INCLUYERON 4 CON NHZ
DOLOR INTRATABLE POR LO MENOS DE 2 AÑOS
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EN UN 82% DISMINUCION DEL DOLOR A LARGO PLAZO CON EVA DE 9 A 1/10 P<0.001
8 PACIENTES ALIVIO COMPLETO DEL DOLOR
2 PACIENTES: RECRUDESCENCIA DEL DOLOR
MEJORIA EN CALIDAD DE VIDA Y SATISFACCION Y USO DE ANALGESICOS P<0.001
EN NHZ: MEJORIA INMEDIATA Y POSTERIOR A 2 MESES
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GRACIAS
La filosofía, como la medicina, hayun montón de drogas, pocos buenos remedios y casi ningúncura específica.