How long should a patient with Herpes Simplex Virus 2 (HSV2) stay on suppressive therapy beyond the initial 6 months?

Duration of HSV2 Suppressive Therapy

For patients with HSV2, suppressive therapy should be continued for at least 6 months, after which discontinuation should be considered to assess the patient's rate of recurrent episodes, as recurrence frequency often decreases over time. 1, 2

Initial Treatment Duration

• Suppressive therapy has been documented as safe and effective for up to 6 years with acyclovir and up to 1 year with valacyclovir and famciclovir 1
• According to the FDA label for valacyclovir, "The efficacy and safety of VALTREX for the suppression of genital herpes beyond 1 year in immunocompetent patients and beyond 6 months in HIV-1−infected patients have not been established" 3
• Daily suppressive therapy reduces the frequency of genital herpes recurrences by ≥75% among patients with frequent recurrences (six or more per year) 1, 2

What Happens After the Initial Treatment Period

• After 1 year of continuous suppressive therapy, discontinuation should be discussed with the patient to assess:
  • The patient's psychological adjustment to genital herpes 1
  • Rate of recurrent episodes, as the frequency of recurrences often decreases over time in many patients 1, 2
• If recurrences remain frequent or severe after discontinuation, suppressive therapy can be restarted 1

Medication Options for Long-term Suppressive Therapy

• Acyclovir 400 mg orally twice daily 1, 2
• Famciclovir 250 mg orally twice daily 2
• Valacyclovir 500 mg orally once daily (for patients with <10 recurrences per year) 4
• Valacyclovir 1 gram orally once daily (for patients with ≥10 recurrences per year) 4
• For patients with HIV, valacyclovir suppressive therapy should be 500 mg twice daily rather than once daily 1

Important Clinical Considerations

• Suppressive treatment reduces but does not eliminate asymptomatic viral shedding 1, 2
• Long-term suppressive therapy (up to 24 months) has been shown to be safe and effective, with minimal side effects 5
• The most common side effects are headache (12%), nausea (6%), and diarrhea (3%), which occur at similar rates to placebo 5
• No laboratory monitoring is needed in patients receiving suppressive therapy unless they have substantial renal impairment 1, 2
• Resistance to antiviral medications is rare in immunocompetent patients but should be suspected if lesions do not begin to resolve within 7-10 days of therapy 1, 2

Special Populations

• For immunocompromised patients (such as those with HIV), higher doses may be needed and longer duration of therapy may be appropriate 1
• For pregnant women with a history of genital herpes, suppressive therapy starting at 36 weeks' gestation can reduce the risk of viral shedding, recurrences, and cesarean deliveries 1

When to Consider Discontinuing Therapy

• After 6-12 months of continuous therapy, consider a trial off medication to assess current recurrence frequency 1, 2
• If recurrences remain infrequent after discontinuation, continued observation without therapy may be appropriate 1
• If recurrences return at a frequency that impacts quality of life, resuming suppressive therapy is appropriate 1, 5