Valaciclovir Dosing for Genital Herpes
For first-episode genital herpes, use valaciclovir 1 gram twice daily for 7-10 days; for recurrent episodes, use 500 mg twice daily for 3-5 days; and for suppressive therapy, use 500 mg to 1 gram once daily depending on recurrence frequency. 1
First Episode (Initial Outbreak)
- Valaciclovir 1 gram twice daily for 10 days is the recommended regimen for initial genital herpes episodes 1
- Treatment is most effective when initiated within 48 hours of symptom onset 1
- This dosing has been shown to be equally effective as aciclovir 200 mg five times daily in achieving lesion healing and reducing viral shedding 2, 3
Recurrent Episodes (Episodic Treatment)
- Valaciclovir 500 mg twice daily for 3 days is the FDA-approved regimen for recurrent genital herpes 1
- The CDC also supports 500 mg twice daily for 5 days as an alternative 4, 5
- Initiate treatment at the first sign or symptom of recurrence (tingling, itching, burning) for maximum effectiveness 6, 1
- Both the 3-day and 5-day regimens are equally effective as aciclovir 200 mg five times daily 2, 7
Suppressive Therapy (Daily Prevention)
Standard Dosing for Immunocompetent Patients
- Valaciclovir 1 gram once daily is the standard suppressive dose for patients with normal immune function 1
- For patients with 9 or fewer recurrences per year, 500 mg once daily is an acceptable alternative 1
- Important caveat: 500 mg once daily is less effective in patients with ≥10 recurrences per year, who should receive 1 gram once daily 4, 5, 8
HIV-Infected Patients
- For HIV-infected patients with CD4+ count >100 cells/mm³, use valaciclovir 500 mg twice daily for suppressive therapy 5, 1
- This higher dosing accounts for potentially more severe and frequent recurrences in immunocompromised individuals 5
Clinical Efficacy and Duration
- Daily suppressive therapy reduces recurrences by ≥75% among patients with frequent episodes 5
- Safety and efficacy have been documented for up to 1 year with valaciclovir 5
- After 1 year of continuous suppressive therapy, consider discussing discontinuation to reassess recurrence frequency, as recurrences often decrease over time 5
Important Safety Considerations
- Avoid high-dose valaciclovir (8 grams per day) in immunocompromised patients due to risk of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome 5, 9
- Standard doses (≤2 grams daily) used for genital herpes have not been associated with this complication 5
- No laboratory monitoring is needed for patients on suppressive therapy unless substantial renal impairment exists 5
- For patients with CrCl 30-49 mL/min, no dose reduction is needed; however, adjust doses for more severe renal impairment 5, 1
Treatment Failure
- If lesions persist after 7-10 days of appropriate valaciclovir therapy, consider HSV resistance 5, 6
- All aciclovir-resistant strains are also resistant to valaciclovir 5
- For aciclovir-resistant HSV, IV foscarnet is the treatment of choice 5