Suppression Therapy for Herpes: Clinical Indications
Suppression therapy for herpes should be initiated for patients with frequent recurrences (≥6 episodes per year), in immunocompromised individuals, and for reducing transmission risk to uninfected partners. 1, 2
Primary Indications for Suppression Therapy
Suppression therapy should be considered in the following scenarios:
- Frequent recurrences: Patients experiencing ≥6 episodes per year 1
- Psychological distress: Patients significantly troubled by their disease 3
- Transmission reduction: To reduce risk of transmission to uninfected partners 2
- Immunocompromised patients: Particularly those with HIV infection with CD4+ counts ≥100 cells/mm³ 1
Medication Options and Dosing
For patients with normal immune function, the following suppressive regimens are recommended:
- Valacyclovir: 1 gram once daily (standard dose) or 500 mg once daily (for patients with ≤9 recurrences per year) 2
- Acyclovir: 400 mg twice daily 1
- Famciclovir: 250 mg twice daily 1
For HIV-infected patients with CD4+ count ≥100 cells/mm³:
Renal Dosing Adjustments
Dose adjustments are necessary for patients with renal impairment:
- For valacyclovir, when creatinine clearance is 10-29 mL/min, reduce to 500 mg every 24 hours 2
- For acyclovir, when creatinine clearance is <10 mL/min, adjust to 800 mg every 12 hours 1
Efficacy of Suppression Therapy
Suppression therapy is highly effective:
- Reduces annual recurrence rates from >12 to approximately 1 per year 4
- 86-90% of patients remain recurrence-free during quarterly assessment periods 5
- Approximately 25% of patients on continuous suppressive therapy remain recurrence-free for up to 5 years 5, 4
- Reduces asymptomatic viral shedding, which may decrease transmission risk 3
Duration of Therapy
While the evidence supports safety and efficacy for up to 5 years 5, consider:
- Periodic reassessment of the need for continued therapy
- Some patients may experience a decrease in recurrence frequency over time, with mean annual recurrences declining from 1.7 in the first year to 0.8 by the fifth year of suppressive therapy 5
Clinical Pearls and Pitfalls
- Pitfall: Failing to recognize asymptomatic viral shedding as a transmission risk. Suppressive therapy reduces asymptomatic viral shedding and may help prevent transmission 3
- Pitfall: Using inadequate dosing. Lower doses (e.g., acyclovir 200 mg once daily) are associated with significantly shorter time to recurrence 6
- Caveat: Even with suppressive therapy, approximately 10-14% of patients may still experience breakthrough recurrences annually 5, 4
- Pearl: Patients with a history of HSV keratitis should receive specialist review and advice to prevent potential vision loss 1
Special Populations
- Immunocompromised patients: Continue treatment until complete healing of lesions 1
- HIV patients: Higher doses may be necessary, with close monitoring for adverse effects 1
- Pediatric patients: Limited data on suppressive therapy; consult specialist guidance
Suppressive therapy has demonstrated excellent safety profiles even with long-term use, with no significant toxic effects or cumulative toxicity detected in studies lasting up to 5 years 5, 4, 7.