Criteria and Medication Regimens for Suppressive Therapy in Genital Herpes
Daily suppressive therapy is recommended for patients with frequent recurrences (≥6 episodes per year) of genital herpes, with several effective medication options including acyclovir 400 mg twice daily, famciclovir 250 mg twice daily, or valacyclovir 1000 mg once daily. 1, 2
Criteria for Initiating Suppressive Therapy
- Suppressive therapy should be considered for patients experiencing 6 or more recurrences of genital herpes per year 1, 2
- Patients with fewer but particularly severe or psychologically distressing recurrences may also benefit from suppressive therapy 2
- Suppressive therapy reduces recurrence frequency by ≥75% in most patients 1, 3
- Suppressive therapy also reduces asymptomatic viral shedding, though it does not completely eliminate the risk of transmission 3
Recommended Medication Regimens for Suppressive Therapy
First-line options:
- Acyclovir 400 mg orally twice daily 1, 2
- Famciclovir 250 mg orally twice daily 1, 4
- Valacyclovir 1000 mg orally once daily 1, 5
- Valacyclovir 500 mg orally once daily (for patients with <10 recurrences per year) 1, 5, 6
Important considerations:
- Valacyclovir 500 mg once daily appears less effective for patients with very frequent recurrences (≥10 episodes per year) 1, 6
- For patients with ≥10 recurrences per year, valacyclovir 1000 mg once daily or 250 mg twice daily is more effective 1, 6
- For HIV-infected patients with CD4+ count ≥100 cells/mm³, valacyclovir 500 mg twice daily is recommended 2, 5
Duration and Monitoring of Suppressive Therapy
- Safety and efficacy have been documented for acyclovir for up to 6 years and for valacyclovir and famciclovir for up to 1 year 1, 2
- After 1 year of continuous suppressive therapy, consider discontinuation to assess the patient's recurrence rate, as frequency often decreases over time 1, 3
- No laboratory monitoring is needed for patients on suppressive therapy unless they have significant renal impairment 3, 5
- Resistance to antiviral medications is rare in immunocompetent patients on suppressive therapy 1
Patient Preference and Quality of Life
- Studies show that most patients (72%) prefer suppressive therapy over episodic treatment for recurrent genital herpes 7
- Suppressive therapy is associated with greater overall treatment satisfaction and improved quality of life compared to episodic therapy 7
- The less frequent dosing regimen of valacyclovir (once daily) may contribute to increased patient adherence to therapy 8
Clinical Pearls and Pitfalls
- The full preventive effect of suppressive therapy builds gradually, with significant reduction in outbreaks typically occurring within the first few weeks of consistent therapy 3
- Patients should be counseled that while suppressive therapy significantly reduces outbreak frequency and viral shedding, it does not completely eliminate the risk of transmission 2, 3
- For patients with renal impairment, dosage adjustments are necessary for all antiviral medications 5, 4
- Valacyclovir and famciclovir may provide increased ease in administration compared to acyclovir, which is an important consideration for prolonged treatment 1