Daily Acyclovir for HSV Suppression
For daily suppressive therapy of recurrent HSV in immunocompetent adults, acyclovir 400 mg orally twice daily is the recommended regimen. 1, 2
Standard Suppressive Dosing
- Acyclovir 400 mg orally twice daily is the primary recommended dose for chronic suppressive therapy 1, 2
- An alternative regimen of acyclovir 200 mg orally 3-5 times daily can be used to identify the lowest effective dose for individual symptom relief 1
- The FDA label confirms 400 mg twice daily for up to 12 months, followed by re-evaluation 2
Indications for Suppressive Therapy
- Suppressive therapy is most appropriate for patients with frequent recurrences (≥6 episodes per year) 1
- Daily suppression reduces recurrence frequency by ≥75% in patients with frequent outbreaks 1
- In clinical studies, 73% of patients remained completely symptom-free on suppressive therapy, with another 14% experiencing only mild symptoms 3
Duration and Re-evaluation
- Safety and efficacy are documented for continuous daily acyclovir therapy for up to 6 years 1
- After 1 year of continuous suppressive therapy, discontinuation should be discussed to reassess the patient's recurrence rate, as frequency naturally decreases over time in many patients 1, 2
- Upon withdrawal, 69% of patients experience relapse within 1-4 weeks, typically returning to their pre-treatment recurrence pattern 3
Important Limitations and Caveats
- Suppressive acyclovir reduces but does not eliminate asymptomatic viral shedding, so the extent to which it prevents HSV transmission remains unknown 1
- Acyclovir neither eradicates latent virus nor affects subsequent risk, frequency, or severity of recurrences after discontinuation 4
- Suppressive therapy has not been associated with emergence of clinically significant acyclovir resistance among immunocompetent patients 1
- Viral susceptibility to acyclovir does not change during long-term treatment 3