Valtrex Treatment Regimen for Herpes Flareups
For recurrent genital herpes flareups, treat with valacyclovir 500 mg orally twice daily for 3 days, initiated at the first sign of prodrome or lesion onset. 1, 2
Episodic Treatment for Recurrent Episodes
Standard Regimen
- Valacyclovir 500 mg orally twice daily for 3 days is the FDA-approved and CDC-recommended first-line treatment for recurrent genital herpes episodes 1, 2
- This 3-day regimen is the shortest FDA-approved course for episodic treatment, offering superior convenience compared to older acyclovir regimens 2, 3
Alternative Regimens (if valacyclovir unavailable)
- Acyclovir 400 mg orally three times daily for 5 days 1
- Acyclovir 800 mg orally twice daily for 5 days 1
- Acyclovir 200 mg orally five times daily for 5 days 1
- Famciclovir 125 mg orally twice daily for 5 days 1
Critical Timing Considerations
- Treatment must be initiated during prodrome or within 1 day of lesion onset for maximum benefit 1, 4
- Provide patients with a prescription or medication supply to enable immediate self-initiation at first symptoms 4
- Efficacy drops significantly if treatment is delayed beyond 24 hours of symptom onset 1
Suppressive Therapy for Frequent Recurrences
When to Consider Suppression
- Recommend daily suppressive therapy for patients with ≥6 recurrences per year 1
- Suppressive therapy reduces recurrence frequency by ≥75% 1, 4
Suppressive Regimens
- Valacyclovir 1 gram orally once daily (standard dose) 1, 2
- Valacyclovir 500 mg orally once daily (alternative for patients with <10 recurrences per year) 1, 2, 5
- Acyclovir 400 mg orally twice daily (if valacyclovir unavailable) 1
- Famciclovir 250 mg orally twice daily (alternative option) 1
Duration and Reassessment
- Suppressive therapy is safe for up to 6 years with acyclovir and 1 year with valacyclovir based on documented safety data 1, 4
- After 1 year of continuous suppression, consider discontinuation to reassess recurrence frequency 1
Special Populations and Considerations
HIV-Infected Patients
- For HIV-infected patients with CD4+ count ≥100 cells/mm³, use valacyclovir 500 mg twice daily for suppressive therapy 2
- These patients may require more aggressive therapy than immunocompetent individuals 6
Renal Impairment
- Dosage adjustment is necessary for patients with reduced renal function 2
- Valacyclovir should be used with caution in patients with impaired renal clearance 7
Immunocompromised Patients
- Suspect acyclovir resistance if lesions do not begin to resolve within 7-10 days of therapy 1
- For proven or suspected resistance, use foscarnet 40 mg/kg IV every 8 hours 1
- Avoid valacyclovir 8 grams per day in immunocompromised patients due to risk of hemolytic uremic syndrome/thrombotic thrombocytopenic purpura 1
Critical Pitfalls to Avoid
What NOT to Use
- Never use topical acyclovir - it is substantially less effective than oral therapy and should be avoided 1, 4, 6
- Topical formulations provide minimal clinical benefit compared to systemic treatment 6
Patient Education Requirements
- Counsel that antiviral medications control symptoms but do not eradicate latent virus or prevent all future recurrences 1, 4
- Advise abstinence from sexual activity when lesions or prodromal symptoms are present 1
- Inform patients that asymptomatic viral shedding can occur, potentially leading to transmission even without visible lesions 1, 4
- Recommend condom use during all sexual exposures with new or uninfected partners 1
When to Extend or Escalate Treatment
- Consider extended treatment beyond the standard course if symptoms persist beyond 5 days 1
- Evaluate for potential co-infections if discharge and pelvic pain persist despite treatment 1
- For severe disease requiring hospitalization (disseminated infection, encephalitis, pneumonitis, hepatitis), use IV acyclovir 5-10 mg/kg every 8 hours instead of oral therapy 6
Herpes Labialis (Cold Sores)
If the flareup involves herpes labialis rather than genital herpes: