Herpes simplex genitalis antiviral treatment of recurrent genital herpes: Difference between revisions
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==Overview== | ==Overview== | ||
All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions). The duration of suppressive therapy is often prolonged, and it may continue up to several years. In contrast, the duration of episodic therapy is limited to a few days. Patients with severe disease require IV antmicrobial therapy. | |||
==Established HSV-2 Infection== | ==Established HSV-2 Infection== | ||
*The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of [[genital]] lesions | *The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of [[genital]] lesions. | ||
*All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions). | |||
*Antiviral therapy for recurrent genital herpes can be administered either episodically to ameliorate or shorten the duration of lesions or continuously as suppressive therapy to reduce the frequency of recurrences. | |||
*Patients with severe disease often require IV antmicrobial therapy. | |||
* | ===Option 1: Suppressive Therapy for Recurrent Genital Herpes==== | ||
*The advantage of suppressive therapy is the reduction of frequency of recurrences. | |||
*Suppressive therapy reduces the risk of recurrence by approximately 70% to 80%. | |||
*The duration of therapy is prolonged. The optimal duration of therapy is not well-established: | |||
:*Suppressive therapy using [[acyclovir]] has been studied for up to 6 years | |||
:*Suppressive therapy using either [[valacyclovir]] or [[famciclovir]] has been studied for up to 1 year | |||
Treatment also is effective in patients with less frequent recurrences. Safety and efficacy have been documented among patients receiving daily therapy with [[acyclovir]] for as long as 6 years and with [[valacyclovir]] or [[famciclovir]] for 1 year. | |||
*1. '''Recurrent genital herpes therapy''' | |||
:*1.1 '''Suppressive therapy''' | |||
::* Preferred regimen: [[Acyclovir]] 400 mg PO bid {{or}} [[Famciclovir]] 250 mg PO bid {{or}} [[Valacyclovir]] 1000 mg PO qd for 7–10 days | |||
::*Alternative regimen: [[Valacyclovir]] 500 mg PO qd for 7–10 days | |||
::*Note (1): Famciclovir is equally effective for episodic treatment of genital herpes but is less effective for suppression of viral shedding | |||
::*Note (2): Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year | |||
===Option 2: Episodic Therapy for Recurrent Genital Herpes=== | |||
* | *1. '''Recurrent genital herpes therapy''' | ||
:*1.2 '''Episodic therapy''' | |||
::* Preferred regimen: [[Acyclovir]] 400 mg PO tid for 5 days {{or}} [[Acyclovir]] 800 mg PO bid a day for 5 days {{or}} [[Acyclovir]] 800 mg PO tid for 2 days {{or}} [[Famciclovir]] 125 mg PO bid for 5 days {{or}} [[Famciclovir]] 1000 mg PO bid for 1 day {{or}} [[Famciclovir]] 500 mg PO once, followed by 250 mg PO bid for 2 days {{or}} [[Valacyclovir]] 1000 mg PO qd for 5 days | |||
::*Alternative regimen: [[Valacyclovir]] 500 mg PO bid for 3 days | |||
::*Note: Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year | |||
== | ==Specific Considerations== | ||
===Severe Disease=== | |||
* | *Severe genital herpes often requires IV antimicrobial therapy. | ||
:*3. '''Severe genital herpes''' | |||
* | ::* Preferred regimen: [[Acyclovir]] 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement {{then}} O antiviral therapy to complete at least 10 days of total therapy. | ||
:::* Note (1): Acyclovir dose adjustment is recommended for impaired renal function. | |||
:::* Note (2): Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type–specific serologic testing for HSV infection. | |||
===HIV-Positive Patients=== | |||
*Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical. | *Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical. | ||
*HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.<ref name="Posavad-2004">{{Cite journal | last1 = Posavad | first1 = CM. | last2 = Wald | first2 = A. | last3 = Kuntz | first3 = S. | last4 = Huang | first4 = ML. | last5 = Selke | first5 = S. | last6 = Krantz | first6 = E. | last7 = Corey | first7 = L. | title = Frequent reactivation of herpes simplex virus among HIV-1-infected patients treated with highly active antiretroviral therapy. | journal = J Infect Dis | volume = 190 | issue = 4 | pages = 693-6 | month = Aug | year = 2004 | doi = 10.1086/422755 | PMID = 15272395 }}</ref> | *HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.<ref name="Posavad-2004">{{Cite journal | last1 = Posavad | first1 = CM. | last2 = Wald | first2 = A. | last3 = Kuntz | first3 = S. | last4 = Huang | first4 = ML. | last5 = Selke | first5 = S. | last6 = Krantz | first6 = E. | last7 = Corey | first7 = L. | title = Frequent reactivation of herpes simplex virus among HIV-1-infected patients treated with highly active antiretroviral therapy. | journal = J Infect Dis | volume = 190 | issue = 4 | pages = 693-6 | month = Aug | year = 2004 | doi = 10.1086/422755 | PMID = 15272395 }}</ref> | ||
*Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy. | *Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy. | ||
* | *HIV-positive patients are also treated similarly using either suppressive or episodic therapy, but the efficacy of antimicrobial therapy is not very well-established.<ref name="Conant-2002">{{Cite journal | last1 = Conant | first1 = MA. | last2 = Schacker | first2 = TW. | last3 = Murphy | first3 = RL. | last4 = Gold | first4 = J. | last5 = Crutchfield | first5 = LT. | last6 = Crooks | first6 = RJ. | title = Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials. | journal = Int J STD AIDS | volume = 13 | issue = 1 | pages = 12-21 | month = Jan | year = 2002 | doi = | PMID = 11802924 }}</ref><ref name="DeJesus-2003">{{Cite journal | last1 = DeJesus | first1 = E. | last2 = Wald | first2 = A. | last3 = Warren | first3 = T. | last4 = Schacker | first4 = TW. | last5 = Trottier | first5 = S. | last6 = Shahmanesh | first6 = M. | last7 = Hill | first7 = JL. | last8 = Brennan | first8 = CA. | title = Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects. | journal = J Infect Dis | volume = 188 | issue = 7 | pages = 1009-16 | month = Oct | year = 2003 | doi = 10.1086/378416 | PMID = 14513421 }}</ref> | ||
* | *HSV type-specific serologies may be offered to HIV-positive persons during their initial evaluation if the infection status is unknown, and suppressive antiviral therapy can be considered among patients who have HSV-2 infection. | ||
==References== | ==References== | ||
Revision as of 20:46, 1 October 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Lakshmi Gopalakrishnan, M.B.B.S.
Overview
All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions). The duration of suppressive therapy is often prolonged, and it may continue up to several years. In contrast, the duration of episodic therapy is limited to a few days. Patients with severe disease require IV antmicrobial therapy.
Established HSV-2 Infection
- The majority of patients with symptomatic, first-episode genital HSV-2 infection subsequently experience recurrent episodes of genital lesions.
- All patients who develop recurrent genital herpes require antimicrobial therapy using either suppressive therapy (less frequency of recurrence) or episodic therapy (less duration of lesions).
- Antiviral therapy for recurrent genital herpes can be administered either episodically to ameliorate or shorten the duration of lesions or continuously as suppressive therapy to reduce the frequency of recurrences.
- Patients with severe disease often require IV antmicrobial therapy.
Option 1: Suppressive Therapy for Recurrent Genital Herpes=
- The advantage of suppressive therapy is the reduction of frequency of recurrences.
- Suppressive therapy reduces the risk of recurrence by approximately 70% to 80%.
- The duration of therapy is prolonged. The optimal duration of therapy is not well-established:
- Suppressive therapy using acyclovir has been studied for up to 6 years
- Suppressive therapy using either valacyclovir or famciclovir has been studied for up to 1 year
Treatment also is effective in patients with less frequent recurrences. Safety and efficacy have been documented among patients receiving daily therapy with acyclovir for as long as 6 years and with valacyclovir or famciclovir for 1 year.
- 1. Recurrent genital herpes therapy
- 1.1 Suppressive therapy
- Preferred regimen: Acyclovir 400 mg PO bid OR Famciclovir 250 mg PO bid OR Valacyclovir 1000 mg PO qd for 7–10 days
- Alternative regimen: Valacyclovir 500 mg PO qd for 7–10 days
- Note (1): Famciclovir is equally effective for episodic treatment of genital herpes but is less effective for suppression of viral shedding
- Note (2): Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year
Option 2: Episodic Therapy for Recurrent Genital Herpes
- 1. Recurrent genital herpes therapy
- 1.2 Episodic therapy
- Preferred regimen: Acyclovir 400 mg PO tid for 5 days OR Acyclovir 800 mg PO bid a day for 5 days OR Acyclovir 800 mg PO tid for 2 days OR Famciclovir 125 mg PO bid for 5 days OR Famciclovir 1000 mg PO bid for 1 day OR Famciclovir 500 mg PO once, followed by 250 mg PO bid for 2 days OR Valacyclovir 1000 mg PO qd for 5 days
- Alternative regimen: Valacyclovir 500 mg PO bid for 3 days
- Note: Valacyclovir 500 mg regimen (alternative regimen) may be less effective among patients with ≥ 10 episodes per year
Specific Considerations
Severe Disease
- Severe genital herpes often requires IV antimicrobial therapy.
- 3. Severe genital herpes
- Preferred regimen: Acyclovir 5–10 mg/kg IV q8h for 2–7 days or until clinical improvement THEN O antiviral therapy to complete at least 10 days of total therapy.
- Note (1): Acyclovir dose adjustment is recommended for impaired renal function.
- Note (2): Symptomatic sex partners should be evaluated and treated in the same manner as patients who have genital lesions. Asymptomatic sex partners of patients who have genital herpes should be questioned concerning histories of genital lesions and offered type–specific serologic testing for HSV infection.
HIV-Positive Patients
- Immunocompromised patients can have prolonged or severe episodes of genital, perianal, or oral herpes. Lesions caused by HSV are common among HIV-infected patients and might be severe, painful, and atypical.
- HSV shedding is increased in HIV-infected persons. Whereas antiretroviral therapy reduces the severity and frequency of symptomatic genital herpes, frequent subclinical shedding still occurs.[1]
- Clinical manifestations of genital herpes might worsen during immune reconstitution after initiation of antiretroviral therapy.
- HIV-positive patients are also treated similarly using either suppressive or episodic therapy, but the efficacy of antimicrobial therapy is not very well-established.[2][3]
- HSV type-specific serologies may be offered to HIV-positive persons during their initial evaluation if the infection status is unknown, and suppressive antiviral therapy can be considered among patients who have HSV-2 infection.
References
- ↑ Posavad, CM.; Wald, A.; Kuntz, S.; Huang, ML.; Selke, S.; Krantz, E.; Corey, L. (2004). "Frequent reactivation of herpes simplex virus among HIV-1-infected patients treated with highly active antiretroviral therapy". J Infect Dis. 190 (4): 693–6. doi:10.1086/422755. PMID 15272395. Unknown parameter
|month=ignored (help) - ↑ Conant, MA.; Schacker, TW.; Murphy, RL.; Gold, J.; Crutchfield, LT.; Crooks, RJ. (2002). "Valaciclovir versus aciclovir for herpes simplex virus infection in HIV-infected individuals: two randomized trials". Int J STD AIDS. 13 (1): 12–21. PMID 11802924. Unknown parameter
|month=ignored (help) - ↑ DeJesus, E.; Wald, A.; Warren, T.; Schacker, TW.; Trottier, S.; Shahmanesh, M.; Hill, JL.; Brennan, CA. (2003). "Valacyclovir for the suppression of recurrent genital herpes in human immunodeficiency virus-infected subjects". J Infect Dis. 188 (7): 1009–16. doi:10.1086/378416. PMID 14513421. Unknown parameter
|month=ignored (help)