What is the recommended treatment for an initial outbreak of genital herpes with valtrex (valacyclovir) 2g dose twice a day (BID) at onset?

Valacyclovir 2g BID is NOT a Standard Dosing Regimen for Genital Herpes

The 2g BID dosing you're asking about is not recommended for genital herpes treatment—this dose is only FDA-approved for cold sores (herpes labialis) as a single-day regimen (2g twice daily for 1 day, 12 hours apart). 1

Correct Dosing for Genital Herpes Based on Clinical Scenario

First Clinical Episode (Initial Outbreak)

• Standard dose: Valacyclovir 1g orally twice daily for 7-10 days 2, 1
• Treatment should be initiated within 48 hours of symptom onset for maximum efficacy 2, 1
• Therapy may be extended beyond 10 days if healing is incomplete 2, 1
• This regimen has equivalent efficacy to acyclovir 200mg five times daily or 400mg three times daily 3

Recurrent Episodes

• Standard dose: Valacyclovir 500mg orally twice daily for 3 days 1
• Initiate at the first sign or symptom of recurrence (prodrome) 1
• Alternative: 1g once daily for 5 days is equally effective 4

Suppressive Therapy

• Standard dose: Valacyclovir 1g once daily 1
• For patients with ≤9 recurrences per year: 500mg once daily 1
• For HIV-infected patients (CD4+ ≥100): 500mg twice daily 1

Critical Pitfall: Cold Sore vs. Genital Herpes Dosing

The 2g BID regimen you mentioned is exclusively for herpes labialis (cold sores), not genital herpes 1. This is a common prescribing error. The cold sore regimen is:

• 2g twice daily for 1 day only (12 hours apart) 1
• Must be initiated at earliest symptom (tingling, itching, burning) 1

Why the Dosing Differs

• Cold sores require ultra-high-dose, short-duration therapy to abort lesion development 1
• Genital herpes requires sustained antiviral levels over 3-10 days depending on whether it's initial or recurrent disease 2, 1
• Using cold sore dosing for genital herpes would provide inadequate treatment duration 1

Clinical Decision Algorithm

If first episode with active lesions:

• Valacyclovir 1g BID × 7-10 days 2, 1

If recurrent episode:

• Valacyclovir 500mg BID × 3 days (or 1g daily × 5 days) 1, 4

If ≥6 recurrences per year:

• Consider suppressive therapy: 1g daily (or 500mg daily if ≤9 recurrences/year) 1

If immunocompromised (HIV with CD4+ ≥100):

• Suppressive: 500mg BID 1
• May require higher doses (up to 400mg acyclovir equivalent 3-5 times daily) for active disease 2