Episodic treatment is taking a short course of valaciclovir at the onset of a recurrence. Those who have less frequent recurrences may find episodic treatment useful. It works best if treatment is taken as soon as warning signs of an impending recurrence (such as neuralgic pain and/or tingling or buzzing sensation in the skin), occur. If taken soon enough, it may stop ulcers developing. It helps to have valaciclovir available beforehand. If you want to use episodic treatment, ask your health care professional to prescribe a supply for you, so you can start the treatment as soon as you feel the symptoms start. As soon as you get the ‘warning’ signs of a herpes recurrence, take valaciclovir 500mg twice daily for 3 days.

Ask your health care professional to provide a prescription of 48 x 500mg valaciclovir tablets so you can self-initiate treatment at the onset of symptoms.

This approach will not have any effect on asymptomatic viral shedding and hence its effect on reducing transmission is not likely to be very significant. Episodic treatment is useful, however, for people who have infrequent attacks or for when people are stopping continuous suppressive therapy.

General practitioners/nurse practitioners are able to prescribe oral antivirals for suppressing herpes. Prescriptions can be filled at retail pharmacies. An increasing number of pharmacists are able to supply an episodic course of antiviral medication for people with a recurrence of facial or genital herpes which may be helpful in situations where patients are unable to access timely appointments with their healthcare provider.

How effective is suppressive therapy?

Studies have proven that continuous suppressive antiviral therapy can dramatically reduce the frequency of outbreaks, or prevent them altogether, and reduces the risk of asymptomatic shedding, normally 2% to 5% of days per year, by 75%. For example, a very large study found that people who had an average of over 12 occurrences a year, could reduce the frequency of their outbreaks to less than two a year after one year of continuous suppressive therapy.

The study also showed that if recurrences do occur during suppressive therapy, they are usually less severe and shorter lasting.

Who is suppressive therapy suitable for?

Taking suppressive therapy, even for a short time, may help you break the cycle and give you a sense of control over the infection.

Suppressive antiviral therapy is suitable for you if any of the following applies to you:

• You want to reduce the risk of transmission to your sexual partner/s
• You are having frequent recurrences.
• You have less frequent but particularly severe or long lasting outbreaks.
• You find recurrences of genital herpes are making you depressed, anxious or withdrawn, or the emotional upset caused to you by genital herpes is disrupting your social activities or sex life. Such feelings can themselves bring on a recurrence and so you can easily get into a vicious cycle.
• You experience severe pain (neuralgia) due to recurrent episodes.
• You have only a few recurrences but they always occur during specific situations, for example, when you have exams or go on holiday. You may wish to start suppressive therapy before you go on holiday and continue on it until you return, thereby reducing the chance of a recurrence.
• You want a worry-free period when getting into a new relationship and are working through when and how to tell.
• You know that stress is a trigger factor for your recurrences, and you are going through a stressful period, for example a new job or a recent death in the family.
• You want to avoid a situation which would be spoilt by a recurrence, for example if you are going on your honeymoon.
• You have another illness which triggers a recurrence of herpes – a course of suppressive therapy may be appropriate until the condition triggering the outbreak has resolved.

How do I take suppressive therapy?

Valaciclovir is the recommended treatment for suppressive therapy in New Zealand. It is a prodrug of aciclovir, meaning that it is converted into aciclovir in the body. Valaciclovir has better absorption, allowing for slower breakdown and less frequent dosing compared to aciclovir, making it more convenient for long-term suppressive therapy.

• Valaciclovir - 500mg tablet, taken once a day. If you start suppressive therapy it is important to take it at the same time every day without missing out days or taking it haphazardly. If you continue to get symptoms on the 500mg dose then talk to your health care professional about increasing the dose.

Suppressive therapy is taken continuously, i.e. daily, for months or even years.

Suppressive antiviral therapy has also been shown to reduce viral shedding between episodes and therefore may help reduce the risk of transmitting the virus to sexual partners. Asymptomatic shedding occurs 2 to 5% days per year. Studies have shown suppressive treatment with valaciclovir reduces transmission of asymptomatic herpes by 75% so nearly eliminating the risk of transmission. Valaciclovir tablets are the recommended treatment for herpes in New Zealand.

Valaciclovir, which is available fully subsidised by prescription, is very safe and effective, even when taken for long periods of time.

For people experiencing the initial or primary episode, a course of valaciclovir tablets can markedly reduce the duration of the episode and give effective relief from symptoms.

Valaciclovir does not eliminate the herpes virus from the body and therefore a course of valaciclovir will not provide a “cure”, but assists in the management of the infection.

How long will I need to take the treatment?

If you choose suppressive therapy, you do not have to stay on it permanently. If you prefer, you can take it until you feel in control of the infection, but this is usually a period of 12 months initially. Your health care professional may suggest you stop the suppressive therapy for a period that is sufficient to establish whether the pattern of recurrence has changed or at least 2 recurrences, in order to assess how active your genital herpes remains. If you are still having problems with recurrences, you and your health care professional may then decide that you should start suppressive therapy again.

Is it safe to take the treatment for a long time?

Valaciclovir has been reported to cause no serious side-effects, even after years of use. A few people taking suppressive therapy do experience minor side-effects such as headache, nausea and diarrhoea. If you have a problem, discuss this with your health care professional. Research to date shows that people with normal immune systems who are on oral antivirals for a long period do not develop virus resistance or clinical breakthrough. Also, there is little interaction with other drugs, e.g. the contraceptive pill is unaffected by valaciclovir or aciclovir.

Will suppressive therapy make it easier to live with genital herpes?

Suppressive therapy may give marked improvement to your emotional well-being. Many people find the fact that they can control the infection gives a boost to their sense of well-being and self-confidence. Even if only taken for a few months, suppressive therapy can help you to come to terms with emotions caused by recurrent genital herpes, including depression and anxiety. Make sure that you continue to talk to a health professional you are comfortable with, at least until you feel completely at ease with having genital herpes.

Due to the potential seriousness of a primary episode of genital herpes for the baby and the relative safety of valaciclovir/aciclovir, it is now recommended that valaciclovir/aciclovir are used for treating a first episode of genital herpes or severe recurrent herpes in the last trimester of pregnancy. It is believed that the benefit of using valaciclovir/aciclovir, by reducing the risk of transmission of herpes to the baby, outweighs the risk of not using it.

A diagnosis of genital herpes often comes as a shock. Adequate information about genital herpes and the implications for the future are an important part of the initial treatment. Counselling offers a way of dealing with any concerns you may have.