Should I extend the course of Valtrex (valacyclovir) for recurrent herpes simplex virus lesions?

Valacyclovir Course Extension for Recurrent HSV Lesions

For recurrent herpes simplex virus lesions, you should NOT extend the standard course of Valtrex (valacyclovir) for episodic treatment, but instead consider switching to daily suppressive therapy if you experience frequent recurrences (≥6 episodes per year). 1, 2

Episodic Treatment vs. Suppressive Therapy

Episodic Treatment

• Standard episodic treatment for immunocompetent patients:
  • Valacyclovir 1000 mg three times daily for 7 days 2
  • Short-course therapy (1-3 days) should NOT be used in immunocompromised patients 1
  • Treatment should continue until lesions have completely healed 1

When to Consider Suppressive Therapy

Suppressive therapy should be considered when:

• You have frequent recurrences (≥6 episodes per year) 2, 3
• Recurrences are severe or cause significant psychological distress 1
• You want to reduce risk of transmission to partners 1, 4

Recommended Suppressive Regimens

For Immunocompetent Patients:

• Valacyclovir 500 mg once daily for patients with <10 recurrences per year 3
• Valacyclovir 1000 mg once daily for patients with ≥10 recurrences per year 3
• Alternative: Valacyclovir 250 mg twice daily 3

For Immunocompromised Patients (including HIV):

• Valacyclovir 500 mg twice daily 1, 2

Efficacy of Suppressive Therapy

• Reduces frequency of outbreaks by 70-80% 2
• Decreases severity and duration of breakthrough episodes 2
• Reduces asymptomatic viral shedding by 71% 4
• Reduces risk of HSV-2 transmission to susceptible partners by 50% 1
• May decrease HIV concentration in plasma and genital secretions in HIV-positive patients 1

Duration of Suppressive Therapy

• After 1 year of continuous suppressive therapy, consider discontinuing to reassess recurrence rate 2
• No specific guidelines exist on maximum duration of suppressive therapy
• Long-term suppressive therapy (>1 year) has been shown to be safe and effective 5, 6

Monitoring and Side Effects

• No laboratory monitoring needed unless you have significant renal impairment 1
• Most common side effects: headache and nausea 5
• Dosage adjustment required for patients with renal impairment 2

Treatment Failure Considerations

• If lesions don't begin to resolve within 7-10 days of starting therapy, treatment failure should be suspected 1
• For suspected acyclovir-resistant HSV, viral culture and susceptibility testing should be performed 1
• Treatment of choice for acyclovir-resistant HSV is IV foscarnet 1

Key Takeaway

Rather than extending the episodic treatment course for a single outbreak, which provides no additional benefit, patients with frequent recurrences should discuss with their provider about switching to daily suppressive therapy, which is more effective for long-term management of recurrent HSV infections.