Treatment guidelines for genital herpes
Treatment guidelines for genital herpes
This month’s question comes from Eileen Swanson, RN, women’s clinic coordinator for Kansas State University’s Lafene Health Center in Manhattan, who asks:
"I had been taught several years ago that patients with severe initial genital HSV [herpes simplex virus] could be given 800 mg acyclovir tid [three times a day] for the initial 72 hours until the patient improves. Now most articles only recommend 800 mg as the dose in HIV-positive individuals. Can you comment on this practice?"
Officials with the Division of STD Prevention at the National Center for HIV, STD, and TB Prevention at the Centers for Disease Control and Prevention (CDC) note the following sections, "First Clinical Episode of Genital Herpes," and a subsection, "HIV Infection," from the 1998 Guidelines for Treatment of Sexually Transmitted Diseases, in offering guidance on this question:1
1. First clinical episode of genital herpes.
Management of patients with first clinical episode of genital herpes includes antiviral therapy and counseling regarding the natural history of genital herpes, sexual and perinatal transmission, and methods to reduce such transmission.
Five percent to 30% of first-episode cases of genital herpes are caused by HSV-1 (herpes simplex virus), but clinical recurrences are much less frequent for HSV-1 than HSV-2 genital infection. Therefore, identification of the type of the infecting strain has prognostic importance and may be useful for counseling purposes.
2. Recommended regimens.
— acyclovir 400 mg orally three times a day for seven to 10 days, or;
— acyclovir 200 mg orally five times a day for seven to 10 days, or ;
— famciclovir 250 mg orally three times a day for seven to 10 days, or;
— valacyclovir 1 g orally twice a day for seven to 10 days.
Note: Treatment may be extended if healing is incomplete after 10 days of therapy.
Higher dosages of acyclovir (i.e., 400 mg orally five times a day) were used in treatment studies of first-episode herpes proctitis and first-episode oral infection, including stomatitis or pharyngitis.
It is unclear whether these forms of mucosal infection require higher doses of acyclovir than used for genital herpes. Valacyclovir and famciclovir probably also are effective for acute HSV proctitis or oral infection, but clinical experience is lacking.
3. HIV infection.
For patients with HIV infection who present with HSV, CDC officials offer the following information:
Immunocompromised patients might have prolonged and/or severe episodes of genital or perianal herpes. Lesions caused by HSV are relatively common among HIV-infected patients, and they may be severe, painful, as well as atypical. Intermittent or suppressive therapy with oral antiviral agents is often beneficial.
The dosage of antiviral drugs for HIV-infected patients is controversial, but clinical experience strongly suggests that immunocompromised patients benefit from increased doses of antiviral drugs.
Regimens such as acyclovir 400 mg orally three to five times a day, as used for other immunocompromised patients, have been useful. Therapy should be continued until clinical resolution is attained. Famciclovir 500 mg twice a day has been effective in decreasing both the rate of recurrences and the rate of subclinical shedding among HIV-infected patients.
OK for immunocompromised
In immunocompromised patients, valacyclovir in doses of 8 g per day has been associated with a syndrome resembling either hemolytic uremic syndrome or thrombotic thrombocytopenic purpura. However, in the doses recommended for treatment of genital herpes, valacyclovir, acyclovir, and famciclovir probably are safe for use in immunocompromised patients. For severe cases, acyclovir 5 mg/kg IV every eight hours may be required.
If lesions persist in a patient receiving acyclovir treatment, resistance of the HSV strain to acyclovir should be suspected. Such patients should be managed in consultation with an expert. For severe cases caused by proven or suspected acyclovir-resistant strains, alternate therapy should be administered. All acyclovir-resistant strains are resistant to valacyclovir, and most are resistant to famciclovir.
Other options available
Foscarnet, 40 mg/kg body weight IV every eight hours until clinical resolution is attained, is often effective for treatment of acyclovir-resistant genital herpes. Topical cidofovir gel 1% applied to the lesions once daily for five consecutive days also might be effective.
Clinicians can reference the 1998 CDC guidelines at the government agency’s Web site: www.cdc.gov/nchstp/dstd/dstdp.html.
Reference
1. Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR 1998; 47(No. RR-1): 20-21, 24.
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