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Recurrent herpes simplex, zoster can be suppressed by long-term oral therapy
Treatment protocols for herpes simplex virus (HSV) and herpes zoster virus (HZV) are continually changing as new medications with less toxicity become available. Oral antivirals play an important role in decreasing recurrence rates as well as reducing the painful symptoms of postherpetic trigeminal neuralgia.
Orals and herpes simplex
Herpes simplex infections of the cornea are traditionally treated with topical medications at the first presentation; however, if the infection is recurrent or if the epithelium is involved, oral antivirals are usually used.
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Primary Care Optometry News Editorial Board member Jill C. Autry, OD, RPh, and her colleagues use oral antivirals when a patient has a dendritic form of herpes on the surface of the cornea, rather than applying a topical antiviral such as Viroptic (trifluridine, Monarch) for an extended period of time.
She said they prescribe one of three treatment regimens for 7 to 10 days: 400 mg of acyclovir five times a day, 250 mg of Famvir (famciclovir, Novartis) three times a day or 500 mg of Valtrex (valacyclovir, GlaxoSmithKline) three times a day.
Paul M. Karpecki, OD, FAAO, a member of the PCON Editorial Board, also uses oral antiviral medication to treat herpes simplex in the ocular primary form, in stromal keratitis and to prevent recurrence.
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“The ocular primary form, which presents as golden colored vesicles on the eyelid, is what children usually acquire, and it can be effectively managed with an oral antiviral,” Dr. Karpecki said.
“Oral antivirals also work well as prophylaxis,” he continued. “We know that the treatment for herpes simplex where you have a stromal keratitis and no epithelial involvement is an anti-inflammatory corticosteroid. But if there were to be any sort of epithelial involvement, we should have some prophylaxis, and an oral antiviral could serve in that role.
Dr. Karpecki also reaches for oral antivirals for patients with stromal keratitis, to prevent further episodes. “Stromal keratitis can be recurrent, and the more it happens the more chance you have of scarring,” he said.
Orals and herpes zoster
When herpes zoster is suspected, Dr. Autry recommends high dosing of an antiviral medication within 72 hours of the onset for the best results.
“These patients generally have lid lesions and lesions into the forehead and into the scalp, and they will often exhibit the inflammatory ocular signs later,” she told PCON in an interview. “If a doctor is unsure if the presentation is zoster, they can use oral antivirals without much concern for consequence. It’s much better to err on the side of caution because the drugs are so well tolerated than to be wrong on the back side and miss the boat, if you will, on getting them started on the medication early for a better result.”
Treatment protocols
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For both herpes simplex and herpes zoster, Primary Care Optometry News Editorial Board member Bruce E. Onofrey, OD, RPh, FAAO, FOGS, prefers to use famciclovir or acyclovir, depending on what the patients’ insurance will cover.
“My preferred drug is famciclovir, but it’s not always covered,” he said. “It has better absorption than other available antivirals. For herpes simplex, I would treat with famciclovir, 250 mg twice a day, or I would use acyclovir 400 mg three times a day. Along with that I would treat them with topical Viroptic usually five times a day.”
For herpes zoster, immediate treatment with an oral antiviral medication will prevent postherpetic trigeminal neuralgia, which can cause excruciating pain on one side of the face, Dr. Onofrey told PCON.
Dr. Karpecki typically uses acyclovir to treat both herpes simplex and herpes zoster, but prefers famciclovir if a herpes zoster condition has been untreated for more than 72 hours.
“I would use 800 mg five times a day for herpes zoster as opposed to 400 mg five times a day or 800 mg three times a day for herpes simplex,” Dr. Karpecki said. “If it’s Valtrex for prophylaxis, it’s going to be 1,000 mg three times a day. I use famciclovir for herpes zoster as well, 500 mg three times a day. Famciclovir can also be very effective after that 72-hour window of a herpes zoster condition, more effective than acyclovir. The one disadvantage is cost; famciclovir is quite a bit more expensive than acyclovir.”
Tests for long-term dosing
Although oral antiviral medications are considered safe, Dr. Autry suggests speaking to patients about their overall health before prescribing them long term to suppress the symptoms of recurrent herpes simplex infection.
“Oral antivirals are probably some of the safest oral medications you can use. But I generally ask patients if they have kidney or liver disease if they’re going to be on it long-term,” she said.
Dr. Karpecki suggests that patients see their primary care physician for lab testing if they are on oral antiviral medication for more than 12 months.
“A lot of medical doctors ascribe to the fact that if you have a medication that’s been prescribed for a full 12 months, you determine if it’s metabolized by the liver or kidneys and then you do enzyme tests related to that,” he said. “In those cases, I will recommend that they see their primary care doctor to run the lab tests.”
New agent on the horizon
The U.S. Food and Drug Administration accepted a New Drug Application from Sirion Therapeutics in January for ganciclovir 0.15%, an acute herpetic keratitis treatment in gel form. According to a company press release, the drug has been available in Europe as a treatment for herpetic viral infections for more than 10 years under the brand name Virgan.
“Virgan or Zirgan, as it will be called in the United States, may be a better replacement for Viroptic in the future,” Dr. Karpecki said. “Ganciclovir works a little bit differently — it inhibits the viral DNA synthesis and it doesn’t seem to be toxic, which is what the real concern was about Viroptic. It may also work for conditions such as epidemic keratoconjunctivitis.”
Dr. Onofrey noted that although punctal stenosis has been reported with the use of several topical antiviral agents, large-scale reviews of the safety and efficacy of topical ganciclovir 0.15% gel by Colin have not mentioned this as a problem.
For more information:
- Jill C. Autry, OD, RPh, is a PCON Editorial Board member and can be reached at the Eye Center of Texas, 6565 West Loop South, Ste. 650, Bellaire, TX 77401; (713) 797-1010; e-mail: jillautry@gmail.com. Dr. Autry has no direct financial interest in the products mentioned in this article, nor is she a paid consultant for any companies mentioned.
- Paul M. Karpecki, OD, FAAO, is director of research in the Cornea and External Disease Service for Koffler Vision Group and a PCON Editorial Board member. He can be reached at Eagle Creek Medical Plaza, 120 N. Eagle Creek Drive, Ste. 431, Lexington, KY 40509; (859) 263-4631; e-mail: paul@karpecki.com. Dr. Karpecki has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.
- Bruce E. Onofrey, OD, RPh, FAAO, FOGS, is a professor at the University of Houston and a PCON Editorial Board member. He can be reached at 505 J. Davis Armistead Bldg. Houston, TX 77204; e-mail: eyedoc3@aol.com. Dr. Onofrey has no direct financial interest in the products mentioned in this article, nor is he a paid consultant for any companies mentioned.