Pharmacologic Therapy

Treatment is based on several factors including likelihood ofpatient compliance, whether it is the first or a recurrent episode, host immunity, and pregnancy. However, patient response has been linked to the time it takes to initiate treatment after symptom onset.

First Episode

The first episode is a systemic illness associated with the vesicular lesions, may last up to 21 days, usually has an uncomplicated course of infection, and in severe cases may require hospitalization. Several agents are effective during this period (Table

3132

80-3). At the cited dosages, these agents have had excellent outcomes with regard to lesion healing time, viral shedding, and loss of pain. Common adverse effects are nausea, headache, and diarrhea.

Episodic Therapy

In a patient with a previous diagnosis of genital herpes, the appearance of new vesicular lesions is synonymous with HSV reactivation. For most patients, genital herpes recurrence is self-limiting and shortlived, lasting approximately 6 to 7 days.

Suppressive Therapy

Suppressive therapy is effective for controlling all symptoms related to the disease and may impact troublesome complications of infection. Before beginning suppressive therapy, discuss patient expectations. Encourage patients to record any breakthrough episodes, as this may require treatment reevaluation and adjustment.

Preventive Therapy

Valacyclovir 500 mg orally once daily has been implicated to prevent the sexual transmission of HSV to an uninfected partner. In addition to pharmacologic therapy, counsel patients regarding safe sex practices.

Drug Resistance

Foscarnet, cidofovir, and trifuridine have been administered in acyclovir-resistant pa-

tients. These agents are usually reserved for use after other agents have failed because of their associated toxicities.

Pregnancy

Women who are pregnant may transmit the virus to the neonate during delivery. There are two management strategies: cesarean section and antiviral therapy. A few studies indicate that acyclovir 200 to 400 mg every 8 hours has been administered from 38 weeks gestation until delivery. The goal of therapy is to reduce the number of lesions and asymptomatic shedding at delivery.

Table 80-3 Comparison of Antivirals Used for Herpes Simplex Infection ftggnt

Side Eflcilj

First Epüsde

VatjCVtkhH

Episodic itjtkni

VMxyciovfc fiRKitlÖ^ir'

Suppttuh*

ValacyclcwH*

Famciclovir

Reserved Agenls

Favunn

Cldofüvii

Tufkiila™

iWT\gorallyrwry4 houa X 7 Kfriayi 400mg orally J lunosdxfy x 7-10 (jays' 200 mq oially every 12 ivjuisw 7-IDfliyi*

J g o/alty Jlirnei doty x 7-IOdayi i ij orjiiy d.>£y x 7-1Q days'

500 mg oially daily* 2-1 [¡days' 2W mg QtHi i cinrxrsdaily v 7 id djys

JW&Q&OllyiWy'lhewi«

800 mg orally 2 limes, daily x S days (V

800nvgoallyJ!im«diii>>: 2djyi SJDmjWJiiy J (imetdWy * 3 (tew 500 mg ouiiy c«o-daily * 5 djys' 1 (i oraify ante daily» 5 dap W> mgrm!!*! Pin»« tXMy x 5 (fori 12i n ig oully Ofiii titty X 5 dJys

200 iwj coiiy J-5* daay-ufno 1

JiimgooJIyirjmesiAaiiyijpNj to

500 mg orally once- daily up to 1 yeai 01

1 goriHyOrKe-tJJilyuOtO'l itMi 250 mg orally J times dally up to 1 ycai

^img/kg r/ every B-1J houis x J-J wfeksof until clinical rewfulkm Is attained d.3%, 1W, aiul 3% topical agsni used ori a compassionate haw foi acytlovn distant herpes

14b topical agenl used fa acytlov* resnlant heipes inflations To 7-M thy!

Htjdache. tonfusioa riausej. vomiting, thrombct/mpwiia, renal InsidlAciency, iasK pn*ims. fever, arthralgias, myalgl* Ihroirbotlc llvombocytopenk purpura, tiallucinatkmSy ummtencc depr eiüon Refer to acyckwlr

Refer tn x yv bvir Refer to acyclovir defer to acyclovir Refer to acyclovir

Refer to acyclovir

Renal insufficiency, metabolic disturbances, hypophosphatemia Applfcationiiie reactions, levodi lec ludesctnce

TransienL burring or stinging, palpobial edema, supeiflcül ipuiKLuJte, kiutCpdLltyXtMrVfes i" im 1 jju.,'. n presiuit

Aafc&rf dam ¡^¡iiHe reifliiMiiirxietJdoijgn-i.CrCl.i iwii'- ¡^¿lejidnce.

tl» Ocflutfj for Gbrae Control jnd Pit^flüon sidto thiidoijgi rnor be useful ic rtiflnupnwnipranHieid patient 'Oiii1 for rirtiWttrjiion in renal jri[\Hii ikhyh (Ci(J 1ft nUMiri or t^i, 'liwfiy adminfciiai Ion In iwl»i imiialrmrnf (C id X miymin or lesfl.

'II rtmMbtacd ihe iame fretiiiency, th«e Is no ewdeiw 1 hai 2W mg or WÖ mg will faonide tgreflier ben?flt tham mt) 'Dose Is based on the number of symptomatic recurrence^ Fiom Bef. 4L

Neonates

Herpes simplex virus infections should be considered in all neonates who present with nonspecific symptoms such as fever, poor feeding, lethargy, or seizures in the first month of life. Infants suspected to have or who are diagnosed with an HSV infection should be treated parenterally. Acyclovir 60 mg/kg/day in three divided doses IV for

14 days for disease limited to skin, eyes, and mucous membranes, and 21 days for CNS or disseminated disease is suggested.

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