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3151 Therapeutics > STIs (HSV - Genital Herpes) > Flashcards

STIs (HSV - Genital Herpes) Flashcards

1
Q

Genital herpes is caused by _______

A

Herpes simplex virus (HSV1 and HSV2)

Mainly caused by HSV2, though there is increasing incidence of HSV1 causing genital herpes a/w oral sex

HSV1 more commonly seen in cold sore

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2
Q

The cycle of HSV infection occurs in five stages.
Briefly elaborate.

A
  1. Primary mucocutaneous infection (in epithelial cell of mucous membrane)
  2. Infection of the nerve ganglia
  3. Establishment of latency (stays dormant in the nerve ganglia)
  4. Can be reactivated (latent viral particles travel from neuron to reinfect the epithelial cells)
  5. Recurrent outbreaks/flairs (viral shedding from epithelial cells can be asymptomatic or symptomatic) (when shedding, transmission can occur)
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3
Q

Transmission of genital herpes can occur via?

A
  • Sexual contact
  • During childbirth
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4
Q

Vesicles develop over ______ days, and heals in _______ weeks

A

Vesicles develop over 7-10 days, and heals in 2-4 weeks

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5
Q

What the 4 ways in which Genital Herpes can be diagnosed?

A
  1. Patient history (previous lesions, sexual contact w lesions)
  2. Presentation/Symptoms
  3. Virulogic test
  4. Type specific (HSV1 or HSV2 serologic test)
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6
Q

What are the presentation/symptoms of Genital Herpes?

A
  • Classical painful multiple vesicular or ulcerative lesions (arised from small blisters), in genital or anal region
  • Local itching, pain, tender inguinal lymphadenopathy (swelling groin lymph nodes)
  • Flu-like syndrome - fever, headache, malaise during first few days after appearance of lesions
  • Prodromal symptoms - mild burning, itching, tingling that occur prior to appearance of recurrent lesions
  • In general, symptoms are less severe in recurrent disease (less lesions, heal faster, milder symptoms, as there is antibodies build up from 1st infection)

FLIP

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7
Q

What virologic tests are used for the diagnostic of genital herpes?

A
  • NAAT (PCR) for HSV DNA from genital lesions
  • Viral cell culture (*but hard to culture, hence PCR preferred)
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8
Q

What serologic tests are used for the diagnostic of genital herpes?

A

Type specific (HSV1 or HSV2) serologic tests

  • Antibodies to HSV develop during the first several weeks after infection and persist indefinitely
  • Serology is not useful for first episode infection as it takes b/w 6-8 weeks for serological detection following a first episode
  • Presence of HSV2 antibody implies anogenital infection
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9
Q

What are the management goals of genital herpes?

A
  • Relieve symptoms
  • Shorten clinical course
  • Prevent complications and recurrences
  • Decrease transmission

*There is no cure for HSV

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10
Q

What supportive care measures can be taken to manage genital herpes?

A
  • Warm saline bath relieves discomfort
  • Symptoms management - analgesia, anti-itch
  • Good genital hygiene to prevent superinfection
  • Counseling regarding natural history/course of infection
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11
Q

What is the MOA of acyclovir and valacyclovir (antivirals) used in genital herpes treatment?

A

Acyclovir inhibits viral DNA polymerase, thereby inhibiting DNA synthesis and replication

*Both acyclovir and valacyclovir have comparable efficacy and tolerability (choice depends on pt compliance and cost)

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12
Q

What are the benefits of antiviral treatment (acyclovir and valacyclovir) in the treatment of genital herpes?

A
  • Reduce viral shedding
  • Reduce duration of symptoms
  • Reduce time to healing
  • Does not prevent latency or affect frequency and severity of recurrent disease after drug is discontinued

*Maximum benefit when initiated at earliest stage of disease (within 72h)
*Topical antivirals discouraged as it offers minimal clinical benefit, and can cause local irritation

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13
Q

[1ST EPISODE]

What are the Acyclovir regimen for 1st episode of genital herpes?

A

PO Acyclovir 400mg TDS x7-10d

IV 5-10mg/kg q8h x2-7 days, complete with PO x10d

[TREATMENT MAY BE EXTENDED IF HEALING INCOMPLETE AFTER 10 DAYS OF THERAPY]

*IV regimen is used for those with severe disease or complications that requires hospitalization, or for the severely immunocompromised such as HIV patients
*Acyclovir has poor bioavailability 10-20%, hence IV required in more severe disease
*Acyclovir has half-life of 3h

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14
Q

[1ST EPISODE]

What are the counseling points for Acyclovir?

A
  • Take without regards to food, after food if GI upset
  • SE: malaise, headache, nausea, vomiting, diarrhea
  • Maintain adequate hydration to prevent crystallization in renal tubules => prevent AKI (*if on IV acyclovir, may need IV fluids for hydration)
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15
Q

[1ST EPISODE]

What are the Valacyclovir regimen for 1st episode of genital herpes?

A

PO Valacyclovir 1g BD x7-10d

[TREATMENT MAY BE EXTENDED IF HEALING INCOMPLETE AFTER 10 DAYS OF THERAPY]

*Valacyclovir is the L-valine ester of acyclovir, converts to acyclovir and valine
*Higher bioavailability of 55% (therefore BD instead of TDS)
*Same half-life of 3h

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16
Q

[1ST EPISODE]

What are the counseling points for Valacyclovir?

A

Per acyclovir: but with headache as the main SE

  • Take without regards to food, after food if GI upset
  • SE: malaise, headache, nausea, vomiting, diarrhea
  • Maintain adequate hydration to prevent crystallization in renal tubules => prevent AKI
17
Q

What are the two pharmacological management options for recurrent genital herpes?

A
  1. Chronic Suppressive Therapy
  2. Episodic Therapy
18
Q

[CHRONIC SUPPRESSIVE THERAPY]

What are the pros of Chronic Suppressive Therapy?

A
  • Reduce frequency of recurrences by 70-80% in pt who have frequent recurrences (>6 per year)
  • Many report no symptomatic outbreaks, improved QoL
  • Established long-term safety and efficacy
  • Decreased risk of transmission (due to reduced viral shedding) *in combi with consistent condom use and abstinence
19
Q

[CHRONIC SUPPRESSIVE THERAPY]

What are the cons of Chronic Suppressive Therapy?

A
  • Compliance
  • Cost
20
Q

[CHRONIC SUPPRESSIVE THERAPY]

What are the recommended regimens for CST?

A

PO Acyclovir 400mg BD

PO Valacyclovir 500mg once daily (if <10 episodes/year)

PO Valacyclovir 1g once daily (If >=10 episodes/year)

21
Q

[CHRONIC SUPPRESSIVE THERAPY]

How should the duration of CST be determined?

A
  • Dependent on patient and disease course
  • Discuss with pt on an annual basis to see if they want to continue CST

*Frequency and severity of recurrence diminishes over time as more antibodies build up, more tolerant to recurrence
*However, once stop CST, frequency may increase again, causing transmission to occur

22
Q

[CHRONIC SUPPRESSIVE THERAPY]

In which group of patient should CST be continued indefinitely?

A
  • Patients with complicated disease course (e.g., disseminated disease - encephalitis, meningitis, keratitis)
  • Immunocompromised hosts (e.g., HIV, autoimmune and on steroids)
23
Q

[EPISODIC THERAPY]

What are the pros of episodic therapy?

A
  • Shorten duration and severity of symptoms
  • Less costly
  • More likely to be compliant
24
Q

[EPISODIC THERAPY]

What are the cons of episodic therapy?

A
  • Does not reduce risk of transmission (since it is episodic, unable to reduce viral shedding that can occur when pt are asymptomatic)
  • Requires initiation of therapy 1. within one day of lesion onset OR 2. during prodrome that precedes some outbreaks
25
Q

[EPISODIC THERAPY]

What are the recommended regimens for episodic therapy?

A

PO Acyclovir 800mg BD x5d

PO Acyclovir 800mg TDS x2d

PO Valacyclovir 500mg BD x3d

PO Valacyclovir 1g once daily x5d

*PO Acyclovir 400mg TDS x5d also effective but not recommended due to frequency of dosing

26
Q

What should be counseled to a person with HSV infection?

A

Educate:

  • On natural history of disease
  • Sexual transmission of HSV can occur during asymptomatic periods
  • Remain abstinent from sexual activity when vesicles/lesions or prodromal symptoms are present to reduce transmission
  • Use latex condoms consistently and correctly to reduce transmission
  • CST can reduce risk of HSV transmission
  • Inform current and future sex partners

Educate on the risks:

  • Risk for neonatal HSV infection (during childbirth)
  • Risk for HIV acquisition (to test and screen periodically)
27
Q

What is the management of sex partners for a HSV infected individual?

A

SYMPTOMATIC sex partners:

  • Evaluated and treated

ASYMPTOMATIC sex partners:

  • Questioned concerning history of genital lesions
  • Encourage to self examine for lesions
  • Seek medical attention if lesions occur
  • May be offered HSV2 serologic testing

3151 Therapeutics (12 decks)

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