Does a patient with resolved HSV-2 symptoms need to continue using Valtrex (valacyclovir)?

Management of HSV-2 After Symptom Resolution

Patients with resolved HSV-2 symptoms do not need to continue Valtrex (valacyclovir) unless they have frequent recurrences or specific risk factors that warrant suppressive therapy. 1

Treatment Options for HSV-2

There are two main approaches to managing HSV-2 after initial symptoms resolve:

1. Episodic Therapy

• Appropriate for patients with infrequent outbreaks (fewer than 6 per year)
• Treatment initiated at first sign of prodrome or within 1 day of lesion onset
• Recommended regimens include:
  • Valacyclovir 500 mg orally twice daily for 5 days 1
  • Acyclovir 400 mg orally three times daily for 5 days 1
  • Acyclovir 800 mg orally twice daily for 5 days 1

2. Suppressive Therapy

• Recommended for patients with:

  • Frequent recurrences (6 or more per year) 1
  • Psychological distress from recurrences
  • Risk of transmission to susceptible partners 1
  • HIV infection 1

• Recommended suppressive regimens:

  • Valacyclovir 500 mg orally twice daily (for HIV-infected patients) 1
  • Valacyclovir 500-1000 mg orally once daily 1, 2
  • Acyclovir 400 mg orally twice daily 1

Decision-Making Algorithm

1. Assess recurrence frequency:

   • <6 recurrences per year → Episodic therapy
   • ≥6 recurrences per year → Consider suppressive therapy

2. Evaluate transmission risk:

   • HSV-2 seronegative partner → Consider suppressive therapy (reduces transmission by 50%) 1
   • No risk of transmission → Episodic therapy may be sufficient

3. Consider immune status:

   • HIV-infected → Higher dose suppressive therapy recommended 1
   • Immunocompetent → Standard dosing appropriate

Key Clinical Considerations

• Suppressive therapy reduces recurrence frequency by ≥75% but does not eliminate asymptomatic viral shedding completely 1, 3
• Valacyclovir appears somewhat more effective than famciclovir for suppression of genital herpes and associated viral shedding 4
• After 1 year of continuous suppressive therapy, discontinuation should be discussed to reassess recurrence frequency, as recurrences often decrease over time 1
• The FDA label for Valtrex notes: "There are no data on the safety or effectiveness of chronic suppressive therapy of more than 1 year's duration in otherwise healthy patients" 5

Important Caveats

• Transmission risk: Even with suppressive therapy, HSV-2 can still be transmitted during asymptomatic shedding periods 1
• Patient counseling: Advise patients that Valtrex is not a cure for genital herpes 5
• Treatment initiation timing: For episodic therapy, treatment should begin at the earliest symptom of recurrence for maximum effectiveness 5
• Quality of life impact: Early suppressive therapy with valacyclovir has been shown to improve herpes-related quality of life, particularly in patients with HSV-2 infection 6

Remember that while symptoms may resolve, HSV-2 remains latent in the body and can reactivate. The decision between episodic and suppressive therapy should be based on recurrence frequency, psychological impact, and transmission risk factors.