From the Guidelines
For patients with frequent or severe recurrent episodes of genital herpes, the recommended prophylactic regimen is oral acyclovir 400 mg twice daily, valacyclovir 500 mg once daily, or valacyclovir 1000 mg once daily, as supported by the most recent guidelines 1. This suppressive therapy should be continued daily for at least 6-12 months initially, after which reassessment can determine if continued therapy is needed based on recurrence frequency.
Key Considerations
- For maximum effectiveness, the medication should be taken consistently at the same times each day.
- Patients should understand that while suppressive therapy significantly reduces outbreaks (by approximately 70-80%) and viral shedding, it does not completely eliminate the risk of transmission to partners, as noted in earlier guidelines 1.
- These antivirals work by inhibiting viral DNA synthesis, preventing herpes simplex virus replication.
- Suppressive therapy is generally well-tolerated with minimal side effects, which may include headache, nausea, or abdominal pain.
- Patients with renal impairment require dose adjustments, and regular follow-up every 6-12 months is recommended to assess efficacy, adherence, and the need for continued therapy, as suggested by various studies 1.
Additional Guidance
- The option for suppressive therapy should be discussed with every HSV-2-infected patient, considering the benefits of reduced recurrences and viral shedding 1.
- Adequate hydration should be maintained while on these medications to minimize potential side effects.
- It is essential to note that while the guidelines provide recommendations, the decision to initiate or continue suppressive therapy should be individualized based on the patient's specific needs and circumstances, taking into account the potential benefits and risks, as well as the patient's preferences and values.
From the FDA Drug Label
Chronic Suppressive Therapy for Recurrent Disease: 400 mg 2 times daily for up to 12 months, followed by re-evaluation Alternative regimens have included doses ranging from 200 mg 3 times daily to 200 mg 5 times daily.
The recommended regimen for prophylactic acyclovir for patients with frequent or severe recurrent episodes of genital herpes is 400 mg twice daily for up to 12 months, followed by re-evaluation. Alternative regimens include doses ranging from 200 mg 3 times daily to 200 mg 5 times daily 2.
From the Research
Prophylactic Acyclovir Regimens for Genital Herpes
The recommended regimen for prophylactic acyclovir for patients with frequent or severe recurrent episodes of genital herpes includes:
- Acyclovir 400 mg, twice daily 3, 4, 5
- Valaciclovir 250 mg, twice daily 3, 6, 4
- Famciclovir 250 mg, twice daily 3, 4
- Valaciclovir 500 mg, once daily 3, 6, 4
Efficacy of Prophylactic Acyclovir
Studies have shown that prophylactic acyclovir is effective in reducing the frequency and severity of genital herpes recurrences:
- A meta-analysis found that oral antiviral treatment reduced the global relative risk of developing at least one recurrence by 47% compared to placebo 4
- A study found that continuous suppressive treatment with acyclovir 400 mg, twice daily, reduced the mean number of recurrences per year from 7.0-12.6 to 1.4-1.9 5
Safety and Tolerability
Prophylactic acyclovir has been shown to be safe and well-tolerated:
- A study found no evidence of cumulative toxicity with continuous suppressive treatment with acyclovir 400 mg, twice daily, for two years 5
- Valaciclovir has been found to be well-tolerated at dosages used to suppress recurrent episodes of genital herpes (500-1000 mg/day) in immunocompetent and HIV seropositive individuals, with headache being the most common adverse event 6