What is the treatment for Monkeypox?

Treatment of Monkeypox

For confirmed or suspected monkeypox cases, most patients require only supportive care as the disease is typically self-limiting, but tecovirimat (TPOXX) should be considered for severe disease, immunocompromised patients, pediatrics, pregnant/breastfeeding women, and when lesions involve high-risk anatomical sites (eyes, mouth, genitals). 1, 2

Supportive Care as Primary Management

• The majority of monkeypox infections are self-limiting with symptoms lasting 2-4 weeks, making supportive care sufficient for most cases 3, 4
• Supportive measures include:
  • Hydration and nutritional support 3
  • Pain management with analgesics 3
  • Antipyretics for fever control 3
  • Wound care for skin lesions to prevent secondary bacterial infection 3

Antiviral Therapy Indications

Tecovirimat (TPOXX) is the first-line antiviral agent, FDA-approved for smallpox treatment and effective against orthopoxviruses including monkeypox. 1, 2

Specific Patient Populations Warranting Antiviral Treatment:

• Immunocompromised patients (HIV/AIDS, cancer, transplant recipients, those on immunosuppressive medications) 2, 5
• Severe disease manifestations 2, 6
• Pediatric patients 2
• Pregnant women 2
• Breastfeeding women 2
• Patients with complicated lesions or secondary bacterial infections 2
• Lesions involving critical anatomical sites: eyes, mouth, or genitals 2

Tecovirimat Dosing and Efficacy:

• Demonstrated 80-100% survival rates in animal models when initiated after clinical signs appeared 1
• Oral administration once daily for 14 days 1
• Dosing based on weight: 10 mg/kg in non-human primate studies 1
• Treatment should ideally begin within 4-6 days of symptom onset based on animal efficacy data 1

Alternative Antiviral Options

When tecovirimat is unavailable or contraindicated, brincidofovir or cidofovir may be considered as second-line agents. 2, 5, 6

• Brincidofovir: Lipid conjugate of cidofovir with improved safety profile, originally developed for smallpox 2, 6
• Cidofovir: Intravenous antiviral with significant nephrotoxicity risk, requiring careful monitoring 2, 6

Vaccinia Immune Globulin Intravenous (VIGIV)

• FDA-approved for treatment of smallpox vaccination complications, available for severe monkeypox cases 3, 2
• May benefit patients with progressive vaccinia, eczema vaccinatum, or severe generalized vaccinia 7
• Available from CDC under Investigational New Drug protocols 7

Infection Control Measures

Isolation of infected patients is critical to prevent transmission, as monkeypox spreads through close contact, respiratory droplets, and contaminated fomites. 8, 5

• Patients are most infectious during the first 7-10 days after rash onset 7
• Transmission occurs via large-droplet nuclei, direct contact with lesions, and contact with contaminated materials (bedding, towels) 7, 2, 5
• Healthcare workers require appropriate personal protective equipment to prevent nosocomial transmission 7

Critical Clinical Pitfalls

• Do not prescribe amoxicillin or ampicillin if concurrent streptococcal pharyngitis is suspected, as this can cause a severe rash in patients with concurrent viral infections 9
• Monkeypox can be mistaken for other vesicular rashes; PCR confirmation is essential for definitive diagnosis 3
• The absence of specific FDA-approved treatment guidelines for monkeypox means clinicians must extrapolate from smallpox treatment protocols 4
• Post-exposure vaccination with JYNNEOS vaccine within 4 days of exposure can prevent disease onset, or within 14 days can reduce disease severity 2

Monitoring and Reporting

• Suspected monkeypox cases constitute a public health emergency and must be reported immediately to state/local health departments 7
• Severe adverse events from any orthopoxvirus treatment should be reported to the Vaccine Adverse Event Reporting System 7
• CDC provides 24-hour consultation at (404) 639-2184, (404) 639-0385, or (770) 488-7100 7