Episodic Treatment of Genital HSV with Valacyclovir
For episodic treatment of recurrent genital herpes, valacyclovir 500 mg orally twice daily for 3-5 days is the recommended regimen, with treatment initiated at the first sign or symptom of an outbreak. 1
Dosing Regimens for Episodic Treatment
Standard Dosing for Recurrent Episodes
- Valacyclovir 500 mg orally twice daily for 3 days is the FDA-approved regimen for treatment of recurrent genital herpes 1
- Alternative regimen: Valacyclovir 500 mg orally twice daily for 5 days is also recommended by the CDC 2, 3
- Both the 3-day and 5-day regimens have demonstrated comparable efficacy to acyclovir 200 mg five times daily 4, 5
Timing of Treatment Initiation
- Initiate therapy at the first sign or symptom of an episode (tingling, itching, or burning) for maximum effectiveness 3, 1
- Treatment is most effective when started during the prodromal phase or within 1 day after onset of lesions 3
- Early initiation can reduce the duration of symptoms, decrease pain, and accelerate healing time 3
First Episode Treatment (Different Dosing)
- For the initial episode of genital herpes, the dose is higher: valacyclovir 1 gram orally twice daily for 10 days 1, 3
- This is distinct from recurrent episode treatment and should not be confused with episodic therapy 1
Special Populations
HIV-Infected Patients
- For episodic treatment in HIV-infected patients: valacyclovir 1000 mg twice daily for 5 days 6
- This higher dose (compared to immunocompetent patients) is comparable to acyclovir 200 mg five times daily in accelerating healing 6
- HIV-infected patients may experience more prolonged or severe episodes requiring adjusted dosing 2
Immunocompromised Patients
- Immunocompromised patients may benefit from increased doses and should be monitored more closely 2, 3
- Avoid valacyclovir doses of 8 g per day due to risk of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome 7, 8
Clinical Pearls and Pitfalls
Administration
- Valacyclovir may be given without regard to meals 1
- The enhanced oral bioavailability (3-5 fold greater than acyclovir) allows for less frequent dosing 8, 9
Treatment Failure
- If lesions do not begin to resolve within 7-10 days of appropriate therapy, suspect HSV resistance 7, 3
- All acyclovir-resistant strains are also resistant to valacyclovir 7
- For resistant HSV, IV foscarnet is the treatment of choice 7
Renal Impairment
- Dose adjustment is necessary for patients with significant renal impairment 7, 9
- No laboratory monitoring is needed in patients with normal renal function 10, 7