Chronic Suppressive Treatment for Oral Herpes
For chronic suppressive therapy of oral herpes (herpes labialis), valacyclovir 500 mg once daily is the recommended first-line treatment option. 1, 2
Recommended Suppressive Therapy Options
First-line options:
Alternative options:
- Famciclovir: 250 mg orally twice daily 3, 4
- Valacyclovir: 1000 mg orally once daily (for patients with very frequent recurrences) 3, 1
Patient Selection for Suppressive Therapy
Suppressive therapy should be considered for patients with:
- Frequent recurrences (≥6 episodes per year) 3, 1
- Significant psychological distress from recurrences
- Immunocompromised status (may require higher dosing) 5
Efficacy of Suppressive Therapy
- Daily suppressive therapy reduces the frequency of herpes recurrences by ≥75% 3
- In clinical studies, 60% of patients on valacyclovir 500 mg daily remained recurrence-free throughout a 4-month treatment period 2
- Mean time to first recurrence was significantly longer with valacyclovir (13.1 weeks) compared to placebo (9.6 weeks) 2
Duration of Therapy
- Safety and efficacy have been documented for:
- After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 3, 1
- Many patients experience a decrease in recurrence frequency over time 3
Special Considerations
Renal Impairment
Dose adjustments are required for patients with renal impairment 1, 4:
| Creatinine Clearance (mL/min) | Valacyclovir Dosing |
|---|---|
| ≥50 (normal) | No adjustment needed |
| 30-49 | No adjustment needed |
| 10-29 | 500 mg every 24 hours |
| <10 | 500 mg every 24 hours |
HIV-Infected Patients
- Higher dosing may be required: valacyclovir 500 mg twice daily or acyclovir 400 mg three times daily 5
- Close monitoring for adverse effects is recommended 5
Important Caveats
- Suppressive therapy reduces but does not eliminate asymptomatic viral shedding 3
- The extent to which suppressive therapy prevents HSV transmission is not fully established 3
- Valacyclovir 500 mg once daily may be less effective for patients with very frequent recurrences (≥10 episodes per year) 3
- No clinically significant acyclovir resistance has been observed among immunocompetent patients on long-term therapy 3, 6
Monitoring
- Assess treatment response and adherence at follow-up visits
- For long-term therapy, consider periodic breaks to reassess the need for continued suppression
- Monitor renal function in patients on prolonged therapy, especially those with underlying renal disease 1, 4
Valacyclovir is often preferred over acyclovir due to its improved bioavailability and less frequent dosing requirements, which may enhance adherence to long-term therapy 7.