What is the recommended treatment for herpes suppression?

Herpes Suppression Treatment

For suppression of recurrent genital herpes, valacyclovir 1 gram once daily is recommended for patients with normal immune function, with an alternative dose of 500 mg once daily for patients with fewer than 9 recurrences per year. 1

Medication Options and Dosing for Herpes Suppression

Valacyclovir

• Standard dosing: 1 gram once daily for chronic suppression 1
• Alternative dosing: 500 mg once daily (for patients with ≤9 recurrences per year) 1
• HIV-infected patients: 500 mg twice daily 1

Famciclovir

• Standard dosing: 250 mg twice daily for chronic suppression 2
• HIV-infected patients: 500 mg twice daily for 7 days (for treatment of recurrent episodes) 2

Dosage Adjustments for Renal Impairment

Valacyclovir Adjustments

Creatinine Clearance (mL/min)	Dosing for Suppressive Therapy
≥50 (normal)	No adjustment needed
30-49	No adjustment needed
10-29	500 mg every 24 hours
<10	500 mg every 24 hours
[3]

Famciclovir Adjustments

Creatinine Clearance (mL/min)	Dosing for Suppressive Therapy
≥40	250 mg every 12 hours
20-39	125 mg every 12 hours
<20	125 mg every 24 hours
Hemodialysis	125 mg following each dialysis
[2]

Special Populations

Immunocompromised Patients

• HIV-infected patients:
  • Valacyclovir: 500 mg twice daily 1
  • Famciclovir: 500 mg twice daily for 7 days (for treatment of recurrent episodes) 2

Patients with Frequent Recurrences

• For patients with ≥10 recurrences per year:
  • Valacyclovir 1 gram once daily is more effective than 500 mg once daily 4
  • Alternatively, valacyclovir 250 mg twice daily can be used 4

Efficacy and Safety Considerations

• Valacyclovir has been shown to be highly effective for suppression of recurrent genital herpes in both immunocompetent and HIV-infected individuals 5, 6
• Long-term suppressive therapy with valacyclovir (up to 24 months) has demonstrated continued efficacy and safety 7
• Valacyclovir significantly reduces the risk of recurrence compared to placebo, with 60% of patients remaining recurrence-free during a 4-month treatment period 8

Patient Education and Monitoring

• Initiate treatment at the earliest sign or symptom of a recurrent episode (e.g., tingling, itching, burning, pain, or lesion) 1, 2
• Counsel patients about:
  • Abstinence during outbreaks or prodromal symptoms
  • Consistent condom use to reduce transmission risk
  • Asymptomatic viral shedding and transmission risk 3
• Monitor for adverse effects:
  • Common: headache, nausea (generally mild and transient) 5
  • Rare: acute renal failure (in patients with underlying renal disease) 2

Clinical Pearls and Pitfalls

• Valacyclovir provides better oral bioavailability than acyclovir, allowing for less frequent dosing 5
• Once-daily regimens offer a useful option for patients requiring suppressive therapy, improving medication adherence 4
• For patients with a history of fewer than 10 recurrences per year, 500 mg of valacyclovir once daily is generally sufficient 4
• Suppressive therapy few weeks before expected delivery can decrease the risk of relapse and need for cesarean section in pregnant women 7