Chronic Suppressive Therapy with Valacyclovir for Genital Herpes
Valacyclovir is strongly recommended for chronic suppressive therapy of recurrent genital herpes, with FDA approval for this indication and demonstrated efficacy in reducing recurrences by ≥75% and decreasing transmission risk to sexual partners. 1, 2
Indications for Suppressive Therapy
Suppressive therapy with valacyclovir should be offered to:
- All patients with symptomatic HSV-2 infection 1
- Particularly those with frequent recurrences (≥6 episodes per year) 3
- Patients experiencing significant psychological distress from recurrences 3
- Individuals seeking to reduce transmission risk to sexual partners 2, 4
Dosing Recommendations
The dosing regimen should be tailored based on recurrence frequency:
For patients with <10 recurrences per year:
- Valacyclovir 500 mg once daily 5
For patients with ≥10 recurrences per year:
- Valacyclovir 1 gram once daily, OR
- Valacyclovir 250 mg twice daily, OR
- Acyclovir 400 mg twice daily 5
For HIV-1-infected patients with CD4+ count ≥100 cells/mm³:
- Valacyclovir 500 mg twice daily 2
Efficacy and Duration
- Suppressive therapy reduces recurrence frequency by ≥75% 3
- Valacyclovir reduces the risk of transmission to sexual partners by 48% overall and 75% for symptomatic infections 4
- Reduces asymptomatic viral shedding from 10.8% to 2.9% of days 4
- Safety and efficacy have been documented for valacyclovir up to 1 year in immunocompetent patients 2, 5
- Long-term studies show continued efficacy with recurrence-free rates of 81-91% across quarterly evaluations 6
Monitoring and Reassessment
- After 1 year of continuous suppressive therapy, consider discontinuation to reassess recurrence frequency 3
- Dose adjustments are required for patients with renal impairment:
- For creatinine clearance 10-29 mL/min: reduce to 500 mg every 24 hours
- For creatinine clearance <10 mL/min: reduce to 500 mg every 24 hours 3
Important Considerations
- Suppressive therapy reduces but does not eliminate asymptomatic viral shedding 3
- No clinically significant acyclovir resistance has been observed among immunocompetent patients on long-term therapy 3
- Valacyclovir is the only antiviral drug approved for once-daily dosing for suppressive therapy of genital herpes 7
- Common side effects are generally mild and include headache (12%), nausea (6%), and diarrhea (3%) 8
- Serious adverse events are rare (0.2%) 8
Limitations
- Efficacy beyond 1 year in immunocompetent patients and beyond 6 months in HIV-1-infected patients has not been established in clinical trials, though observational data supports longer use 2
- Efficacy for transmission reduction beyond 8 months in discordant couples has not been established 2
- Not established for reduction of transmission in individuals with multiple partners or non-heterosexual couples 2
Valacyclovir suppressive therapy has demonstrated significant benefits in quality of life by reducing the physical and psychological burden of recurrent genital herpes while also decreasing transmission risk to partners, making it an important treatment option for patients with recurrent disease.