Acyclovir Indications and Dosage
- Bell’s palsy †
- cytomegalovirus (CMV) †
- cytomegalovirus (CMV) infection prophylaxis †
- encephalitis
- Epstein-Barr virus †
- esophagitis †
- hairy leukoplakia †
- herpes genitalis
- herpes genitalis prophylaxis
- herpes labialis
- herpes labialis prophylaxis †
- herpes simplex infection prophylaxis †
- herpes simplex ocular infection prophylaxis †
- herpes simplex virus infection
- herpes simplex virus type 1
- herpes simplex virus type 2
- herpes zoster
- keratoconjunctivitis †
- pharyngitis †
- pneumonitis †
- postherpetic neuralgia prophylaxis †
- proctitis †
- stomatitis †
- tracheobronchitis †
- varicella (chickenpox)
- varicella prophylaxis †
- varicella-zoster virus
- viral conjunctivitis
†non-FDA-approved indication
Acyclovir Indications and Dosage
The following viruses are generally considered susceptible to acyclovir in vitro: Epstein-Barr virus †; cytomegalovirus (CMV) †; herpes simplex virus type 1; herpes simplex virus type 2; varicella-zoster virus.
For the treatment of herpes simplex virus infection:
- for limited non-life threatening infections (e.g., herpes labialis or herpes fibrilis):
Oral dosage (initial infection):
Adults and adolescents: The CDC recommends 400 mg PO three times per day or 200 mg PO five times per day for 7-10 days or until clinical resolution occurs. Alternatively, 800 mg PO every 8 hours for 7-10 days or 200-400 mg PO 5 times per day for 10 days has also been recommended.
Children: 1000 mg/day PO in 3-5 divided doses for 7-14 days. Maximum dosage is 80 mg/kg/day.
Oral dosage (recurrent infection):
Adults and adolescents: The CDC recommends 400 mg PO three times per day for 5 days; 200 mg PO five times per day for 5 days; or 800 mg PO twice daily for 5 days, initiated at the first sign of prodrome or lesions.
Topical dosage:
Adults and children: Apply sufficient quantity of cream or ointment to adequately cover all lesions every 3 hours, 6 times a day for 7 days, initiate at the first sign of symptoms or lesions. The dose size per application will vary depending upon the lesion area but should approximate 1/2-inch ribbon of ointment per 4 square inches of surface area.
- for treatment of initial or recurrent herpes genitalis:
Intravenous dosage (initial infection):
Adults and adolescents: 5 mg/kg IV every 8 hours for 5 days. Use ideal body weight when dosing obese adult patients.
Oral dosage (initial infection):
Adults and adolescents: 200 mg PO every 4 hours, 5 times per day for 10 days. The CDC recommends 400 mg PO three times per day for 7-10 days or 200 mg PO five times per day for 7-10 days.
Children: 400 mg PO three times per day for 7-10 days. Maximum dosage is 80 mg/kg/day.
Oral dosage (recurrent infection in immunocompetent patients):
Adults and adolescents: 200 mg PO every 4 hours, five times a day for 5 days, initiated at the first sign or symptom or recurrence. The CDC recommends 400 mg PO three times per day for 5 days; 200 mg PO five times per day for 5 days; or 800 mg PO twice daily for 5 days, initiated at the first sign of prodrome or genital lesions.
Children: 400 mg PO three times per day or 800 mg PO twice per day for 5 days. Maximum dosage is 80 mg/kg/day.
Oral dosage (recurrent infection in HIV infected patients):
Adults and adolescents: The CDC recommends 400 mg PO three times per day for 5-10 days or 200 mg PO five times per day for 5-10 days.
Topical dosage (immunocompetent patients only):
Adults and children: Apply sufficient quantity of ointment to adequately cover all lesions every 3 hours, 6 times a day for 7 days. The dose size per application will vary depending upon the lesion area but should approximate 1/2-inch ribbon of ointment per 4 square inches of surface area. Therapy should be initiated as early as possible following signs and symptoms. There is no clinical benefit of the ointment in immunocompetent patients; although, decreased viral shedding may be noted.
- for the treatment of herpes simplex encephalitis:
Intravenous dosage:
Adults and adolescents: 10 mg/kg IV every 8 hours for 10 days. Because relapses of herpes simplex encephalitis have been reported after only 10 days of therapy, some clinicians recommend treatment for 14-21 days. Some references suggest a dose of 12.5 mg/kg IV every 8 hours. The CDC recommends 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution is attained. Use ideal body weight when dosing obese adult patients.
Children and infants 6 months to 12 years: 500 mg/m2 IV or 10 mg/kg IV every 8 hours for 10 days. Because relapses of herpes simplex encephalitis have been reported after only 10 days of therapy, some clinicians recommend treatment for 14-21 days.
Neonates †: 10 mg/kg IV every 8 hours for 14-21 days; a duration of 10 days has also been used successfully. Higher dosages of 15-20 mg/kg IV every 8 hours have also been used. Because relapses of herpes simplex encephalitis have been reported after only 10 days of therapy, some clinicians recommend treatment for 14-21 days.
- for the treatment of herpes simplex infection in patients with severe disease or in those with complications necessitating hospitalization, such as disseminated infection, pneumonitis †, esophagitis †, tracheobronchitis †, proctitis †, stomatitis †, or pharyngitis †:
NOTE: Dosage for herpes simplex encephalitis is listed separately.
Intravenous dosage:
Adults and adolescents: The CDC recommends 5-10 mg/kg IV every 8 hours for 5-7 days or until clinical resolution of the herpes simplex infection is attained. For tracheobronchitis, a dose of 8 mg/kg IV every 8 hours for 7-10 days has been used. Use ideal body weight when dosing obese adult patients.
Children and infants 6 months to 12 years: 250-500 mg/m2 or 5-10 mg/kg IV every 8 hours for 5-7 days for infections without CNS involvement.
Neonates from birth to 3 months of age: 10 mg/kg IV every 8 hours for 10 days for infections without CNS involvement. Doses of 15 mg/kg or 20 mg/kg IV have been used, however, the safety and efficacy of these doses are not known.
Preterm neonates †: 10 mg/kg IV every 12 hours for 14-21 days for infections without CNS involvement.
Oral dosage:
Adults and adolescents: The CDC recommends 400 mg PO three to five times per day for 10 days or until clinical resolution occurs. Alternatively, 800 mg PO every 8 hours for 7-10 days or 200-400 mg PO 5 times per day for 10 days has also been recommended.
Children: 1000 mg/day PO in 3-5 divided doses for 7-14 days. Maximum dosage is 80 mg/kg/day.
- for treatment of viral conjunctivitis, specifically herpes simplex keratoconjunctivitis †:
Ophthalmic dosage (not currently available in US) †:
Adults: Fifty-nine patients with dendritic keratitis were randomized in a double-blind study to receive either 3% acyclovir ophthalmic ointment or 2% trifluorothymidine ointment. One-half inch ribbon of 3% acyclovir ophthalmic ointment was applied to affected eye(s) 5 times per day. The success rate was 87% for acyclovir and 82% for trifluorothymidine.
Intravenous dosage:
Neonates: A dosage of 10 mg/kg IV every 8 hours for 10 days has been recommended for neonates with infection confined to the skin, eyes, or mouth.
For herpes simplex infection prophylaxis †, including herpes labialis prophylaxis †:
- for chronic suppression therapy of recurrent herpes genitalis (i.e., herpes genitalis prophylaxis) in immunocompetent patients:
Oral dosage:
Adults and adolescents: 400 mg PO twice daily for up to 12 months then reevaluate. Although acyclovir therapy has been shown to be safe and effective for up to 6 years, the decision to continue therapy should be reevaluated every year.
Children †: 800-1000 mg/day PO in 2-5 divided doses. Total dose should not exceed 80 mg/kg/day.
- for primary prophylaxis in herpes simplex sero-positive recipients of a bone marrow transplant †:
Intravenous dosage:
Adults: A dosage of 250 mg/m2 IV every 8 hours beginning 1 day prior to transplant and continuing until marrow engraftment has been recommended. Use ideal body weight when dosing obese adults.
- for primary herpes simplex prophylaxis in immunocompromised HSV-seropositive patients †:
Oral dosage:
Adults and children: 600-1000 mg/day PO in 3-5 divided doses during the period of risk. Maximum dosage in children is 80 mg/kg/day.
Intravenous dosage:
Adults and children: 250 mg/m2 IV every 8 hours during the period of risk. Use ideal body weight when dosing obese adult patients.
- for secondary herpes simplex infection prophylaxis in HIV-infected patients with frequent and/or severe recurrences †:
Oral dosage:
Adults and adolescents: The CDC recommends 400-800 mg PO 2-3 times per day.
Children and infants: The CDC recommends 80 mg/kg/day PO in 3-4 divided doses.
- for secondary herpes simplex ocular infection prophylaxis †:
Oral dosage:
Adults and adolescents: In one study, patients >= 12 years with ocular HSV disease (e.g., blepharitis, conjunctivitis, epithelial keratitis, stromal keratitis, or iritis) were randomized to acyclovir 400 mg PO twice daily or placebo. At 12 months, study medications were stopped and patients were monitored for 6 additional months. The cumulative probability of a recurrence of any type of ocular HSV disease was significantly lower in the acyclovir group compared to placebo. There was no rebound in disease recurrence after acyclovir prophylaxis was stopped.
For the treatment of herpes zoster (shingles):
- for treatment of herpes zoster (shingles) in bone marrow and organ transplant patients, patients receiving chemotherapy, and other immunocompromised patients:
Intravenous dosage:
Adults: 10 mg/kg IV every 8 hours for 7 days. Use ideal body weight when dosing obese adult patients.
Children: 500 mg/m2 or 10 mg/kg IV every 8 hours for 7-10 days.
- for treatment of herpes zoster (i.e., shingles) and postherpetic neuralgia prophylaxis † in immunocompetent patients:
Oral dosage:
Adults: 800 mg PO every 4 hours, five times a day for 7-10 days. Initiate therapy within 48-72 hours of rash onset. During trials, therapy was begun within 72 hours of rash onset and was most effective if started within the first 48 hours. Adults > 50 years of age showed the greatest benefit. A meta-analysis including 30 clinical trials of the treatment of herpes zoster determined that treatment with acyclovir 800 mg/day PO within 72 hours of rash onset may reduce the incidence of residual pain at 6 months by 46% in immunocompetent adults.
- for treatment of acute herpes zoster ophthalmicus † in immunocompetent patients:
Oral dosage:
Adults: 600 mg PO every 4 hours 5 times per day for 10 days. Initiate therapy within 72 hours but no later than 7 days of rash onset.
For the treatment of varicella (chickenpox):
- for treatment of varicella in immunocompetent patients:
Oral dosage:
Adults and children > 40 kg: 800 mg PO 4 times per day for 5 days. Initiate therapy at the first signs of symptoms (i.e., within 24 hours). Treatment with acyclovir has been shown to shorten the time to healing, reduce the number of lesions, reduce the number of vesicles, and reduce other symptoms such as fever, anorexia, and lethargy.
Children >= 2 years of age: 20 mg/kg (not to exceed 800 mg) PO four times per day for 5 days initiated at the first sign of symptoms has been recommended.
Intravenous dosage:
Adults: In a case report, acyclovir 20 mg/kg/day IV in three divided doses for 5 days was used successfully. Use ideal body weight when dosing obese adult patients.
- for treatment of varicella in immunocompromised patients:
Intravenous dosage:
Adults and children >= 12 years: A dosage of 10 mg/kg IV every 8 hours for 7-10 days has been recommended. Use ideal body weight when dosing obese adult patients.
Children < 12 years: A dosage of 500 mg/m2 every 8 hours for 7-10 days has been recommended.
For primary varicella prophylaxis † in HIV-infected patients with significant exposure to chickenpox or shingles for patients who have no history of either condition or, if available, negative antibody to varicella-zoster virus (VZV):
Oral dosage:
Adults and adolescents: The CDC recommends 800 mg PO 5 times a day for 3 weeks as an alternative to varicella-zoster immune globulin; however, data are lacking on the effectiveness of acyclovir for preventing varicella zoster in susceptible HIV-infected patients.
For cytomegalovirus (CMV) infection prophylaxis †:
- for prevention of CMV infection in immunocompromised patients:
Intravenous dosage:
Adults and children: A dosage of 500 mg/m2 IV every 8 hours during the period of risk has been used. Use ideal body weight when dosing obese adult patients.
- for prevention of CMV infection in CMV-seropositive patients receiving bone marrow tranplantation
:
Intravenous dosage:
Adults: In one study, 500 mg/m2 IV every 8 hours starting 5 days before transplantation and continuing for 30 days after transplant was successful in patients seropositive for antibody to CMV before bone marrow transplantation. Dosage was adjusted for patients with compromised renal function. Despite high doses of acyclovir, CMV infection developed in 59% and pneumonia developed in 19% of the treated group. Use ideal body weight when dosing obese adult patients.
Children: A dosage of 500 mg/m2 IV every 8 hours has been studied.
- for prevention of CMV infection in CMV-seronegative recipients of CMV-seropositive renal allografts:
Oral dosage:
Adults: A dosage of 800 mg PO 6 hours prior to transplantation, followed by 800 mg PO 24 hours after transplantation, followed by 800 mg PO four times per day has been utilized. Dosage was adjusted for patients with compromised renal function.
For the treatment of hairy leukoplakia † in HIV-positive adults:
Oral dosage:
Adults: A dose of 800 mg PO every 6 hours for 20 days was found effective in an open label study of a small number of HIV-positive men. After therapy was discontinued, recurrences developed in all 5 patients who had initially responded.
For the treatment of Bell’s palsy †:
Oral dosage:
Adults: 400 to 800 mg PO five times per day for 7 days, given with prednisone, has been recommended.
Maximum Dosage Limits:
- Adults: 60 mg/kg/day IV; 3200 mg/day PO.
- Adolescents: 60 mg/kg/day IV; 3200 mg/day PO.
- Children: 60 mg/kg/day IV; 80 mg/kg/day PO or 3200 mg/day PO, whichever is less.
- Infants: see indications.
- Neonates: see indications.
Patients with hepatic impairment:
No dosage adjustment needed.
Patients with renal impairment:
CrCl > 50 ml/min: no dosage adjustment needed.
CrCl 25-50 ml/min: extend IV dosing interval to every 12 hours. No adjustment required for oral dosage regimens.
CrCl 10-24 ml/min: extend IV dosing interval to every 24 hours. For patients receiving 800 mg PO five times per day, the dosage interval should be extended to every 8 hours. No dosage adjustment is necessary for patients receiving 400 mg PO every 12 hours or 200 mg PO five times per day.
CrCl < 10 ml/min: reduce recommended IV dose by 50% and extend dosing interval to every 24 hours. For patients receiving 200 mg PO five times per day or 400 mg PO every 12 hours, reduce dose to 200 mg PO every 12 hours. For patients receiving 800 mg PO five times per day, reduce dose to 800 mg PO every 12 hours.
Intermittent hemodialysis:
See oral dosage for CrCl < 10 ml/min. If using IV dosing, extend the intravenous dosing interval to every 24 hours and adjust the dosing schedule so a dose is administered after each dialysis session. Alternatively, some clinicians recommend a dose of 2.5 mg/kg IV every 24 hours, with a supplemental dose of 2.5 mg/kg IV given after each standard dialysis session.
Continuous hemodialysis (CAVHD, CVVHD):
Definitive dosage recommendations have not been established. Acyclovir is significantly removed by CAVHD or CVVHD. A dose 1.3 times that used for anuric nondialyzed patients has been recommended, assuming a combined dialysis and ultrafiltrate flow rate of 1.5 L/hr.
Peritoneal dialysis:
Extend the intravenous dosing interval to every 24 hours. Supplemental systemic doses do not appear to be necessary following peritoneal dialysis.
†non-FDA-approved indication
[ Last revised: 12/3/2004 4:44:00 PM ]
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