Acyclovir Preventative Dose for HSV Suppression

Standard Suppressive Dosing Regimens

The CDC guidelines recommend acyclovir 400 mg orally twice daily as the preferred preventative dose for HSV suppression, with treatment continued for up to 12 months followed by re-evaluation 1
Alternative dosing options for HSV suppression include acyclovir 200 mg orally 3-5 times daily 3, valacyclovir 250 mg orally twice daily 1, valacyclovir 500 mg orally once daily 1, and famciclovir 250 mg orally twice daily 1

Suppressive therapy with acyclovir reduces HSV recurrence frequency by at least 75% in patients with frequent recurrences (≥6 episodes per year) 3
The CDC guidelines recommend that after 1 year of continuous suppressive therapy, acyclovir should be discontinued to reassess the patient's recurrence rate 1
Suppressive acyclovir reduces but does not eliminate asymptomatic viral shedding 1
The extent to which suppressive therapy prevents HSV transmission remains unknown 1

For HIV-infected/immunocompromised patients, higher doses of acyclovir (400 mg orally 3-5 times daily) are often beneficial 1
Famciclovir 500 mg twice daily has been effective in decreasing recurrence rates and subclinical shedding in HIV-infected patients 1

The CDC guidelines recommend avoiding valacyclovir 500 mg once daily in patients with very frequent recurrences (≥10 episodes per year), as this regimen appears less effective than other dosing options 1
High-dose valacyclovir (8 g/day) should be avoided in immunocompromised patients due to association with hemolytic uremic syndrome or thrombotic thrombocytopenic purpura 1
Complete prevention of transmission or asymptomatic shedding should not be expected with suppressive therapy 1