What is the recommended suppressive therapy regimen for patients with genital herpes?

Recommended Suppressive Therapy for Genital Herpes

For patients with frequent recurrences of genital herpes (6 or more per year), the recommended suppressive therapy is valacyclovir 1 gram once daily or acyclovir 400 mg twice daily. 1, 2

First-Line Suppressive Therapy Options

Valacyclovir

• Standard dosing: 1 gram once daily 2
• Alternative dosing: 500 mg once daily (for patients with 9 or fewer recurrences per year) 2
• For HIV-infected patients: 500 mg twice daily (if CD4+ count ≥100 cells/mm³) 2

Acyclovir

• Standard dosing: 400 mg orally twice daily 1
• Alternative dosing: 200 mg orally 3-5 times daily 1

Famciclovir

• Standard dosing: 250 mg twice daily 3

Efficacy of Suppressive Therapy

• Suppressive therapy reduces recurrence frequency by at least 75% in patients with frequent episodes 1
• Valacyclovir suppressive therapy is associated with:
  • Decreased risk of recurrence by 78% compared to episodic treatment 4
  • Greater patient satisfaction and improved quality of life 4
• Early suppressive therapy with valacyclovir has been shown to reduce symptomatic recurrent outbreaks, especially in patients with HSV-2 infection 5

Duration of Therapy

• The safety and efficacy of famciclovir for suppression of recurrent genital herpes beyond 1 year have not been established 3
• Suppressive therapy can be continued as long as the patient experiences frequent recurrences
• Consider periodic reassessment to determine ongoing need for suppressive therapy

Renal Dosage Adjustments

Valacyclovir

Creatinine Clearance (mL/min)	Dosage Adjustment
≥50 (normal)	No adjustment needed
30-49	No adjustment needed
10-29	500 mg every 24 hours
<10	500 mg every 24 hours
[1]

Acyclovir

Creatinine Clearance (mL/min)	Dose 200 mg	Dose 400 mg
>25	200 mg every 4 hours, 5 times a day	400 mg every 12 hours
10-25	200 mg every 4 hours, 5 times a day	400 mg every 12 hours
0-10	200 mg every 12 hours	200 mg every 12 hours
[1]

Special Populations

HIV-Infected Patients

• Valacyclovir: 500 mg twice daily (if CD4+ count ≥100 cells/mm³) 2
• Higher oral doses may be required, especially with CD4+ counts <200 cells/µL 1

Elderly Patients

• May require dose adjustment due to age-related changes in renal function 1
• Monitor renal function and adjust dosage accordingly

Patient Education and Prevention

• Inform patients that suppressive therapy:
  • Reduces frequency of outbreaks by 70-80%
  • Decreases severity and duration of breakthrough episodes
  • Reduces asymptomatic viral shedding 1
• Advise patients to:
  • Abstain from sexual activity while lesions are present
  • Use condoms during all sexual exposures
  • Understand the potential for recurrent episodes and asymptomatic transmission 1
• Women of childbearing age should inform healthcare providers during pregnancy 1

Common Pitfalls to Avoid

• Underdosing antivirals can lead to treatment failure and increased risk of complications
• Failure to adjust dosage for patients with renal impairment can lead to adverse effects
• Not recognizing underlying immunocompromise which may require higher dosing or longer treatment
• Premature discontinuation of therapy can lead to recurrence or prolonged symptoms 1