What is the recommended treatment for monkeypox?

Monkeypox Treatment Guidelines

Tecovirimat is the recommended first-line antiviral treatment for monkeypox in severe cases or immunocompromised patients, while supportive care is the mainstay of treatment for most cases. 1

Treatment Algorithm

First-Line Management: Supportive Care

For most patients with monkeypox, supportive care is sufficient as the disease is typically self-limiting:

• Pain management with appropriate analgesics
• Adequate hydration
• Wound care for lesions
• Isolation until all lesions have crusted over and fallen off (typically 2-4 weeks)
• Frequent handwashing with soap and water or hand sanitizers containing >60% alcohol 1

Indications for Antiviral Therapy

Antivirals should be considered for patients with:

1. Severe disease (>100 lesions, high fever, significant constitutional symptoms)
2. Immunocompromised status (particularly those with advanced HIV with CD4 <200 cells/μL)
3. Complications (encephalitis, pneumonia, retropharyngeal abscess)
4. Lesions in critical locations (near eyes, mouth, genitals)
5. Risk of severe disease (pregnant women, children) 1, 2

Antiviral Options

First-Line Antiviral: Tecovirimat

• Dosage: 600 mg twice daily orally for 14 days 1
• Mechanism: Inhibits viral envelope formation by targeting the VP37 envelope protein 3
• Availability: Available through expanded access programs 2
• Considerations: Resistance monitoring may be necessary in patients who fail to respond or experience disease recrudescence 3

Alternative Antivirals:

• Cidofovir: Consider when tecovirimat is ineffective
  • Limitations: Nephrotoxicity, available only intravenously 1, 4
• Brincidofovir: Another alternative option
  • Note: Cross-resistance between tecovirimat and brincidofovir is not expected due to different mechanisms of action 3, 5

Immune Globulin Therapy

• Vaccinia Immune Globulin Intravenous (VIGIV) may be beneficial in severe cases 5, 2
• Primarily used when antivirals are ineffective or contraindicated

Infection Control Measures

• Place used bandages in sealed plastic bags before disposal 1
• Avoid direct contact with lesions
• Maintain isolation until all lesions have crusted and fallen off
• Healthcare workers should use appropriate personal protective equipment

Prevention

• Vaccination is recommended for high-risk individuals and post-exposure prophylaxis
• Two available vaccines:
  1. JYNNEOS™ (live, non-replicating vaccinia virus) - preferred option with 66-86% efficacy 2
  2. ACAM2000® (live, replicating vaccinia virus) 1, 5

Special Considerations

Immunocompromised Patients

• Higher risk of severe disease and complications
• Early antiviral therapy is strongly recommended
• More intensive monitoring may be required 2

Pregnant Women and Children

• Require careful evaluation and consideration for antiviral therapy
• Limited data on safety of antivirals in these populations
• Benefit-risk assessment should guide treatment decisions 6

Clinical Monitoring

• Monitor for secondary bacterial infections of skin lesions
• Watch for signs of dehydration, particularly with extensive oral lesions
• Assess for ocular involvement which may require ophthalmologic consultation
• Evaluate for respiratory symptoms which may indicate pulmonary involvement 6

The treatment approach should prioritize preventing mortality and morbidity through appropriate supportive care and timely use of antivirals in patients at risk for severe disease.