What is the recommended daily maintenance dose of Acyclovir (antiviral medication) for an immunocompetent adult with a history of recurrent herpes simplex virus (HSV) or varicella-zoster virus (VZV) infections?

Acyclovir 800 mg Daily Maintenance Dosing

Acyclovir 800 mg once daily is NOT the recommended dose for suppressive therapy of recurrent HSV infections; the standard suppressive regimen is acyclovir 400 mg orally twice daily. 1, 2

Standard Suppressive Therapy Dosing

The CDC guidelines and FDA labeling clearly establish the following suppressive regimens for recurrent genital herpes 1, 2:

• Acyclovir 400 mg orally twice daily (standard recommendation)
• Alternative: Acyclovir 200 mg orally 3-5 times daily (for dose titration to lowest effective dose)

The 800 mg dose is reserved for episodic treatment (800 mg twice daily for 5 days), NOT for daily suppressive therapy. 1, 2

Clinical Efficacy and Duration

• Daily suppressive therapy reduces genital herpes recurrence frequency by ≥75% in patients with frequent recurrences (≥6 episodes per year) 1
• Safety and efficacy documented for continuous acyclovir therapy up to 6 years 1
• After 1 year of continuous suppressive therapy, discontinuation should be discussed to reassess recurrence rate, as frequency often decreases over time 1
• Suppressive therapy has not been associated with clinically significant acyclovir resistance in immunocompetent patients 1

Special Population Considerations

Immunocompromised Patients (Including HIV)

• May require higher suppressive doses: acyclovir 400 mg orally 3-5 times daily 3, 4
• One protocol suggests 400 mg five times daily for acute episodes, then 400 mg three times daily for 1-2 months, followed by 400 mg twice daily for long-term suppression 4

Herpes Zoster (Shingles)

• Acyclovir 800 mg is used for episodic treatment of herpes zoster: 800 mg orally 5 times daily for 7-10 days 2
• This is NOT a maintenance regimen but acute treatment 2

Important Caveats

• Suppressive acyclovir reduces but does not eliminate asymptomatic viral shedding, so transmission risk remains 1
• The medication does not eradicate latent virus or affect subsequent recurrence risk after discontinuation 5
• Valacyclovir and famciclovir offer alternative suppressive options with less frequent dosing (once or twice daily), which may improve adherence for prolonged treatment 1, 6

Dosing Errors to Avoid

Do not confuse episodic treatment doses with suppressive doses:

• Episodic: 800 mg twice daily for 5 days 1, 2
• Suppressive: 400 mg twice daily continuously 1, 2

Using 800 mg once daily represents neither the standard episodic nor suppressive regimen and lacks evidence-based support for either indication.