What are the CDC guidelines for suppressive therapy in patients with genital herpes?

CDC Guidelines for Suppressive Therapy in Genital Herpes

The CDC recommends daily suppressive antiviral therapy as the primary management strategy for patients with frequent genital herpes recurrences (≥6 episodes per year), with valacyclovir 500 mg to 1 g once daily as the preferred regimen for immunocompetent patients. 1

Primary Indications for Suppressive Therapy

• Patients experiencing ≥6 recurrences per year are the primary candidates for daily suppressive therapy 1
• Daily suppressive therapy reduces recurrence frequency by ≥75% in patients with frequent outbreaks 1, 2
• Suppressive therapy reduces asymptomatic viral shedding (though does not eliminate it completely), potentially decreasing transmission risk to sexual partners 1, 2
• This approach improves quality of life by preventing physical discomfort, psychological distress, and social impact of recurrent outbreaks 1

CDC-Recommended Dosing Regimens

For Immunocompetent Patients:

• Valacyclovir 500 mg once daily for patients with <10 recurrences per year 1, 3
• Valacyclovir 1,000 mg once daily for patients with ≥10 recurrences per year 1, 3
• Acyclovir 400 mg twice daily as an alternative option 1, 2
• Famciclovir 250 mg twice daily as another effective alternative 1, 2

For HIV-Infected Patients:

• Valacyclovir 500 mg twice daily (NOT once daily) for patients with CD4+ count ≥100 cells/mm³ 1, 3
• This higher dosing is critical—the CDC explicitly warns against prescribing 500 mg once daily for HIV-infected patients 1

Duration and Reassessment Strategy

• Suppressive therapy has documented safety for up to 6 years with acyclovir and 1 year with valacyclovir 1, 4
• After 1 year of continuous suppressive therapy, discontinuation should be discussed to assess the patient's psychological adjustment to genital herpes and current recurrence rate 1, 2, 4
• The CDC recommends continuing therapy for at least 6 months before considering discontinuation 4
• If recurrences remain frequent or severe after discontinuation, suppressive therapy can be restarted 4
• Recurrence frequency often decreases over time in many patients, making periodic reassessment valuable 4

Safety Profile and Monitoring

• No laboratory monitoring is needed in patients receiving suppressive therapy unless they have substantial renal impairment 1, 4
• Acyclovir, valacyclovir, and famciclovir are occasionally associated with nausea or headache, but these are generally mild 1
• No clinically significant acyclovir resistance has emerged in immunocompetent patients receiving suppressive therapy 1

Critical Safety Warnings

• Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome (TTP/HUS) has been reported in HIV-infected patients treated with high-dose valacyclovir (8 g/day), but has NOT been reported at doses used for suppressive therapy of HSV infection 1
• The CDC advises against using valacyclovir 8 g per day due to this association with HUS/TTP in immunocompromised patients 2

Management of Treatment Failure

• Treatment failure related to resistance should be suspected if lesions do not begin to resolve within 7-10 days after initiation of therapy 1, 2, 4
• For suspected acyclovir-resistant HSV, viral culture should be obtained and susceptibility testing performed if virus is isolated 1
• IV foscarnet is the treatment of choice for acyclovir-resistant HSV 1, 2

Essential Patient Counseling Points

• Suppressive therapy does not eradicate the virus or completely prevent transmission—asymptomatic viral shedding can still occur 1, 2
• Patients should be counseled to abstain from sexual activity when lesions or prodromal symptoms are present 2
• Patients should inform sex partners about having genital herpes and use condoms during all sexual exposures with new or uninfected partners 2
• Genital herpes is a recurrent, incurable viral disease; antiviral medications control symptoms but do not eradicate the virus or prevent all recurrences 2

Common Pitfalls to Avoid

• Never prescribe topical acyclovir—the CDC recommends against its use due to substantially lower effectiveness compared to oral therapy 2
• Never use valacyclovir 500 mg once daily for HIV-infected patients—they require 500 mg twice daily 1
• Do not assume suppressive therapy eliminates transmission risk—counsel patients that asymptomatic shedding persists 1, 2