What is the recommended treatment for monkeypox?

Recommended Treatment for Monkeypox

Tecovirimat (TPOXX) is the first-line treatment for severe monkeypox cases or high-risk patients, administered orally once daily for 14 days. 1, 2

Treatment Algorithm

First-Line Treatment:

• Supportive care is sufficient for most cases of monkeypox with mild and self-limited disease 3, 4
  • Pain control
  • Hydration
  • Fever management
  • Skin lesion care

When to Consider Antiviral Therapy:

Antivirals should be initiated for patients with:

1. Severe disease manifestations
2. Immunocompromised status (particularly advanced HIV with CD4 <200 cells/μL)
3. Pediatric patients
4. Pregnant or breastfeeding women
5. Complicated lesions
6. Lesions near the mouth, eyes, or genitals 3, 5

Antiviral Options:

1. Tecovirimat (TPOXX):

   • First-line antiviral therapy
   • Dosing: Oral administration once daily for 14 days
   • Demonstrated significant improvement in survival in animal studies with orthopoxvirus infections 2
   • Available through expanded access programs 4

2. Alternative antivirals:

   • Brincidofovir
   • Cidofovir
   • Trifluridine ophthalmic solution (for ocular lesions) 5, 6, 7

3. Vaccinia Immune Globulin Intravenous (VIGIV):

   • Can be considered for severe cases
   • Available through expanded access programs 5, 6

Prevention and Infection Control

• Frequent hand washing with soap and water or alcohol-based (>60%) hand sanitizers 1
• Avoid close contact with infected individuals
• Avoid sharing bedding, towels, or utensils with infected persons 1
• Isolation of infected patients to prevent transmission 8

Special Considerations

Severe Manifestations Requiring Prompt Treatment:

• Ocular lesions
• Neurologic complications
• Myopericarditis
• Mucosal lesions (oral, rectal, genital, urethral)
• Uncontrolled viral spread in immunocompromised patients 5

Vaccination

• Two FDA-approved vaccines are available: JYNNEOS (live, replication incompetent vaccinia virus) and ACAM2000 (live, replication competent vaccinia virus)
• Vaccination is recommended for high-risk populations with efficacy of 66% to 86% 3, 4

Clinical Course

• Incubation period: 7-10 days (median)
• Prodromal symptoms: fever (62%-72%), lymphadenopathy (56%-86%), myalgia (31%-55%), malaise (23%-57%), headache (25%-55%)
• Skin lesions progress through 4 stages (macules, papules, vesicles, pustules) over 2-4 weeks
• Most cases are self-limited with low mortality rate (<0.2% in US) 4

Important Caveats

1. The effectiveness of tecovirimat for treatment of orthopoxvirus infections in humans has not been determined in controlled clinical trials, as such trials are not feasible or ethical 2

2. Treatment recommendations are based on animal studies, limited human case reports, and expert opinion rather than randomized controlled trials 5

3. Randomized controlled trials and other carefully controlled research studies are urgently needed to evaluate the effectiveness of medical countermeasures for treating human monkeypox 5

4. Early initiation of antiviral therapy may be more effective, as demonstrated in animal studies where treatment was most effective when started within 4-5 days of infection 2