Suppressive Therapy for Herpes Simplex Virus (HSV)
For patients with frequent or severe HSV outbreaks, daily suppressive therapy with valacyclovir 500 mg once daily (for <10 recurrences/year) or 1 gram once daily (for ≥10 recurrences/year) is the recommended first-line treatment. 1, 2
Recommended Suppressive Therapy Options
First-Line Options:
- Valacyclovir 500 mg once daily for patients with <10 recurrences per year 1, 3
- Valacyclovir 1 gram once daily for patients with ≥10 recurrences per year 1, 3
- Valacyclovir provides better bioavailability than acyclovir and allows for more convenient once-daily dosing 4, 5
Alternative Options:
Special Populations
HIV-Infected Patients:
- Valacyclovir 500 mg twice daily (not once daily) is recommended for HIV-infected patients 6, 7
- Acyclovir 400 mg twice daily is an alternative option 6
- Daily suppressive therapy in HIV-infected persons may also decrease HIV concentration in plasma and genital secretions 6
Pregnancy:
- Acyclovir is the preferred agent during pregnancy due to more extensive safety data 6
- Episodic therapy rather than suppressive therapy is generally preferred during pregnancy unless there are frequent severe recurrences 6
Clinical Benefits of Suppressive Therapy
- Reduces frequency of recurrences by ≥75% among patients with frequent outbreaks 6, 7
- Decreases asymptomatic viral shedding, though does not eliminate it completely 7, 8
- Improves quality of life by reducing physical and psychological impact of recurrences 5, 9
- May reduce risk of transmission to sexual partners, though protection is not complete 2, 7
Duration of Therapy and Monitoring
- Safety and efficacy have been documented for up to 6 years with acyclovir and 1 year with valacyclovir 2, 7
- After 1 year of continuous suppressive therapy, consider discontinuation to reassess the patient's rate of recurrent episodes 6, 7
- No laboratory monitoring is needed unless the patient has substantial renal impairment 6, 7
Important Clinical Considerations
- Suppressive therapy should be discussed with every HSV-2-infected patient, especially those with frequent recurrences (≥6 episodes per year) 6, 2
- Treatment should be initiated promptly for maximum effectiveness 2, 10
- Patients should be counseled that suppressive therapy reduces but does not eliminate the risk of viral transmission 2, 7
- Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome has been reported with high-dose valacyclovir (8 g/day) but not at doses used for HSV suppression 6, 7, 4
Treatment Failure
- Treatment failure related to resistance should be suspected if lesions do not begin to resolve within 7-10 days of therapy 6
- For acyclovir-resistant HSV, IV foscarnet is the treatment of choice 6
- Viral culture and susceptibility testing should be performed in immunocompromised patients with suspected resistance 6