What is the suppressive treatment for Herpes Simplex Virus (HSV)?

From the Guidelines

Suppressive therapy for herpes simplex virus (HSV) should be initiated with valacyclovir 500 mg twice daily in HIV-infected persons, or with acyclovir or famciclovir twice-daily regimens, to prevent recurrences and reduce transmission risk. The goal of suppressive therapy is to reduce the frequency of outbreaks and viral shedding, thereby improving quality of life and reducing the risk of transmission to uninfected partners. According to the most recent guidelines 1, daily anti-HSV therapy is recommended for persons who have frequent or severe recurrences. The medications commonly used for suppressive therapy include valacyclovir, acyclovir, and famciclovir, with valacyclovir being often preferred due to its convenient dosing and good absorption.

Key Considerations

• Suppressive therapy should be discussed with every HSV-2-infected patient, especially those with frequent or severe recurrences 1.
• The treatment regimen should be tailored to the individual patient's needs, with consideration of factors such as kidney function and potential drug interactions.
• While suppressive therapy significantly reduces outbreaks and transmission risk, it does not completely eliminate either, and patients should be counseled on the importance of safe sex practices and regular follow-up appointments.

Treatment Options

• Valacyclovir: 500 mg twice daily in HIV-infected persons 1.
• Acyclovir: 400 mg twice daily.
• Famciclovir: 250 mg twice daily.

Monitoring and Follow-up

• Kidney function should be monitored in patients with existing kidney issues.
• Patients should be reassessed after 1 year of continuous suppressive therapy to determine if the frequency of outbreaks has changed, and to discuss the patient's psychological adjustment to genital herpes 1.

From the FDA Drug Label

Suppressive therapy:Two randomized, double-blind, placebo-controlled, 12-month trials were conducted in 934 immunocompetent adults with a history of 6 or more recurrences of genital herpes episodes per year. Comparisons included famciclovir 125 mg three times daily, 250 mg twice daily, 250 mg three times daily, and placebo At 12 months, 60% to 65% of patients were still receiving famciclovir and 25% were receiving placebo treatment. Recurrence rates at 6 and 12 months in patients treated with the 250 mg twice daily dose are shown in Table 8 Table 8: Recurrence Rates at 6 and 12 Months in Adults with Recurrent Genital Herpes on Suppressive Therapy Recurrence Rates at 6 Months Recurrence Rates at 12 Months Famciclovir 250 mg twice daily (n=236) Placebo (n=233) Famciclovir 250 mg twice daily (n=236) Placebo (n=233) Recurrence-free 39% 10% 29% 6% Recurrences † 47% 74% 53% 78% Lost to follow-up ‡ 14% 16% 17% 16% †Based on patient reported data; not necessarily confirmed by a physician. ‡Patients recurrence-free at time of last contact prior to withdrawal. Famciclovir-treated patients had approximately one-fifth the median number of recurrences as compared to placebo-treated patients.

The recommended dose for suppressive therapy of genital herpes is 250 mg twice daily 2.

• Recurrence rates were lower in patients treated with famciclovir compared to placebo.
• Recurrence-free rates were higher in patients treated with famciclovir compared to placebo. The use of higher doses of famciclovir was not associated with an increase in efficacy.

From the Research

Suppressive HSV Treatment Options

• Daily antiviral therapy with famciclovir and valacyclovir has been shown to be effective in reducing both symptomatic and asymptomatic reactivation of herpes simplex virus type 2 (HSV-2) when compared to placebo 3.
• Valacyclovir appears to be somewhat better than famciclovir for suppression of genital herpes and associated shedding 3.
• A dose-response relationship was observed across the once-daily valaciclovir regimens, with 500 mg of valaciclovir once daily being effective for patients with a history of < 10 recurrences per year, and 1 g of valaciclovir once daily, 250 mg of valaciclovir twice daily, or 400 mg of acyclovir twice daily being more effective in patients with > or = 10 recurrences per year 4.

Treatment Approaches

• The treatment of herpes simplex infections can be approached through intermittent episodic therapy, intermittent suppressive therapy, or chronic suppressive therapy, with the choice of approach depending on defined clinical characteristics and patient preference 5.
• Oral acyclovir, valacyclovir, and famciclovir are efficacious and safe for the treatment of the first episode and recurrent genital herpes and are useful as suppressive therapy for individuals with frequent genital herpes recurrences 6.

Antiviral Therapy

• Valacyclovir is a highly bioavailable prodrug of acyclovir and has been shown to be effective in the treatment of herpes simplex, herpes zoster, and other viral infections 7.
• Valacyclovir is the only oral antiviral agent approved for therapy of herpes labialis, and is also approved for a 3-day course in the episodic treatment of recurrent genital herpes, as well as for once daily dosing for suppressive therapy 7.
• Valacyclovir is safe and effective in the therapy of patients with herpes simplex and herpes zoster, and may be useful in other viral infections 7.