What is the treatment for monkeypox?

Treatment for Monkeypox

The primary treatment for monkeypox is supportive care, with antivirals such as tecovirimat indicated for severe cases, immunocompromised patients, or when lesions are near critical areas like the eyes, mouth, or genitals. 1

Treatment Algorithm

First-Line Management: Supportive Care

• Pain management with appropriate analgesics
• Adequate hydration and nutritional support
• Meticulous wound care for lesions
• Isolation until all lesions have crusted over 1, 2

Indications for Antiviral Therapy

Antivirals should be considered in the following situations:

1. Immunocompromised patients (especially those with advanced HIV with CD4 count <200 cells/μL)
2. Severe disease (>100 lesions, high fever, significant constitutional symptoms)
3. Complications (encephalitis, pneumonia, retropharyngeal abscess)
4. Lesions in critical locations (near eyes, mouth, or genitals) 1, 2

Antiviral Options

First-Line Antiviral:

• Tecovirimat
  • Dosage: 600 mg twice daily orally for 14 days 1, 3
  • Mechanism: Inhibits viral envelope formation
  • FDA-approved for smallpox treatment under the Animal Rule 3
  • Available through expanded access programs 2

Alternative Antivirals:

• Cidofovir
  • Consider when tecovirimat is ineffective
  • Limitations: nephrotoxicity, only available intravenously 1
• Brincidofovir
  • Note: Cross-resistance between tecovirimat and brincidofovir is not expected due to distinct mechanisms of action 3, 4

For Ocular Involvement:

• Trifluridine ophthalmic solution 5
• Evaluation by an ophthalmologist is required 6

For Severe Cases:

• Vaccinia Immune Globulin Intravenous (VIGIV) may be considered for severe manifestations 4, 5

Infection Control Measures

Personal Hygiene:

• Frequent handwashing with soap and water or alcohol-based hand rub (>60% alcohol) 1
• Avoid direct contact with lesions 1

Environmental Control:

• Contaminated clothing, towels, and bedding should be laundered in hot water with bleach 1
• Place used bandages in sealed plastic bags 1

Isolation:

• Maintain isolation until all lesions have crusted over 1, 2
• Use contact and respiratory precautions in healthcare settings 1

Special Considerations

Immunocompromised Patients:

• Higher risk of severe disease and death, particularly with advanced HIV 2
• Lower threshold for antiviral therapy 1, 2

Complications to Monitor:

• Secondary bacterial infections
• Ocular involvement (can lead to vision loss)
• Neurologic complications
• Myopericarditis
• Mucosal lesions (oral, rectal, genital, urethral) 5

Prevention

• Vaccination with JYNNEOS™ (live non-replicating vaccinia virus) or ACAM2000® (live replicating vaccinia virus) for pre- or post-exposure prophylaxis 1, 4
• JYNNEOS™ vaccine has shown 66-86% efficacy 2

Clinical Pearls and Pitfalls

• Pitfall: Delaying antiviral therapy in high-risk patients can lead to worse outcomes. Consider early treatment in immunocompromised individuals.
• Pitfall: Failing to monitor for resistance. Consider resistance if patients fail to respond to therapy or experience disease recrudescence after initial improvement 3.
• Pearl: Most monkeypox cases are self-limited with low mortality (<0.2% in the US), but can be severe in immunocompromised patients 2.
• Pearl: The timing of antiviral initiation is crucial; animal studies show better outcomes when treatment is started earlier in the disease course 3.

While randomized controlled trials are still needed to definitively establish the effectiveness of these treatments 5, the current approach based on the most recent evidence provides a framework for managing monkeypox infections with a focus on supportive care and targeted use of antivirals for high-risk cases.