DiseaseHERPES SIMPLEX VIRUS                                State                                            Presentation  ...
OBJECTIVES                   THE PURPOSE OF THIS PRESENTATION IS TO: D e f i ne h e r p e s s i m pl e x v i r us P r o ...
HerpesBACKGROUND   Simplex             Virus
DEFINITION Herpes simplex viruses are host -adapted pathogens that  cause a wide variety of disease states Double-strand...
EPIDEMIOLOGY By age 30, 50% of those in a high socioeconomic status  an 80% in a lower socioeconomic status are seroposit...
TRANSMISSION Humans are the only  natural reservoirs Transmission occurs by  close personal contact Infection occurs by...
TYPES OF HERPES SIMPLEX VIRUS          HSV-1                        HSV-2 Traditionally associated    Traditionally asso...
COMPLICATIONS Bacterial and fungal super -       CNS I nvolvement  infections                           Aseptic Meningi...
CLINICAL   Herpes                SimplexPRESENTATIONS   Virus
HERPES SIMPLEX VIRUS TYPE 1                      Herpes Labialis         Most common manifestation of          recurrent ...
HERPES SIMPLEX VIRUS TYPE 1            Acute Herpetic Gingivostomatits         Primarily seen in younger patients (6     ...
HERPES SIMPLEX VIRUS TYPE 1           Acute Herpetic Pharyngotonsilitis         Pharyngotonsilitis is seen more often    ...
PRIMARY (FIRST EPISODE)               GENITAL HERPES May be caused by either type of HSV   Clinical features are indisti...
PRIMARY GENITAL HERPES                Men Vesicles appear in the glans  penis and prepuce, or shaft of  the penis   May ...
PRIMARY GENITAL HERPES                       Women       Vesicles appear on the external        genitalia, labia minora a...
RECURRENT GENITAL HERPES 90% of patients are reactivated with genital herpes within  the first 12 months   HSV-2 is reac...
SUBCLINICAL GENITAL HERPES Most primary HSV infections are asymptomatic   70-80% of seropositive individuals have no kno...
HerpesDIAGNOSIS   Simplex            Virus
LABORATORY STUDIES          The criteria for standard diagnosis includes isolation of                           the virus ...
DIFFERENTIAL DIAGNOSES Candidiasis: Fungal infection Chancroid: STD and Cofactor in HIV transmission Hand-foot-and-mout...
PHARMACOLOGICAL    Herpes                   Simplex      TREATMENTS   Virus
MEDICATION THERAPY GOALS Reduce morbidity Prevent complications
HSV THERAPY Antiviral Agents   These agents are nucleoside analogs that are phosphorylated    by thymidine kinase to for...
RECOMMENDED REGIMENS FOR           GENITAL HERPES          First Episode                                    Suppressive Th...
ACYCLOVIR (ZOVIRAX®) Used for both types of HSV Side effects     Malaise     Nausea, vomiting     Pruritus     Acute...
ACYCLOVIR (ZOVIRAX®)      Adult Dosing                          Pediatric Dosing Initial Treatment:                     ...
ACYCLOVIR (ZOVIRAX®) FormulationsFormulation                       Unit Count             Estimated PriceGeneric 200mg Ca...
ACYCLOVIR TOPICAL   (ZOVIRAX® OINTMENT OR CREAM) IMPORTANT NOTE: This formulation has no clinical  benefit for recurrent ...
ACYCLOVIR AND HYDROCORTISONE          (XERESE®) Used to treat herpes labialis in patients over 12 years Recommended Adul...
FAMCICLOVIR (FAMVIR®) Used for both types of HSV Dose renally when CrCl is less  than 60mL/min due to risk of  acute ren...
FAMCICLOVIR (FAMVIR®)      Adult Dosing                  Pediatric Dosing Recurrent Herpes Labialis       Safety and eff...
FAMCICLOVIR (FAMVIR®) FormulationsFormulation             Unit Count   Estimated PriceGeneric 125mg Tablets   30 tabs    ...
PENCICLOVIR (DENAVIR®) Used topically for        Adult Dosing  Herpes Labialis                 Apply Q2H x 4 days      ...
VALACYCLOVIR (VALTREX®) Used for both types of HSV Provides an advantage as it reduces the  risk of heterosexual transmi...
VALACYCLOVIR(VALTREX®)      Adult Dosing             Pediatric Dosing Recurrent Herpes           Safety and efficacy  La...
VALACYCLOVIR (VALTREX®) FormulationsFormulation             Unit Count   Estimated PriceGeneric 1g Tablets      30 tabs  ...
DOCOSANOL (ABREVA®) Available over the counter for the treatment of herpes  labialis Mechanism of Action:   Inhibits th...
TOPICAL OVER-THE-COUNTER AGENTS       FOR HERPES LABIALIS    The following medications may be recommended over the  counte...
PREVENTION AND   Herpes                 Simplex     FOLLOW-UP   Virus
PREVENTION Latex condoms are recommended to minimize exposure  to genital herpes infections   Ulcers may occur outside o...
PHARMACISTS ROLE     Compliance       Encourage adherence to medication        regimens to decrease transmissions      ...
REFERENCES C e n t e r s f o r D i s e as e C o n t r o l an d P r e v e n ti o n. “ G e n i t al HS V I n f e c tio n s”...
Disease State Presentation: Herpes Simplex Virus
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Disease State Presentation: Herpes Simplex Virus

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Presented during Community Pharmacy Rotation at Walgreens in Oakland Park, Florida.

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  • This is real take it serious, who will believe that a herb can cure herpes, i navel believe that this will work i have spend a lot when getting drugs from the hospital to keep me healthy, what i was waiting for is death because i was broke, one day i hard about this great man who is well know of HIV and cancer cure, i decided to email him, unknowingly to me that this will be the end of the herpes in my body, he prepare the herb for me, and give me instruction on how to take it, at the end of the one month, he told me to go to the hospital for a check up, and i went, surprisingly after the test the doctor confirm me negative, i thought it was a joke, i went to other hospital was also negative, then i took my friend who was also herpes positive to the Dr Agumagu, after the treatment she was also confirm negative . He also have the herb to cure cancer. please i want every one with this virus to be free, that is why am dropping his email address, agumaguspelltemple@outlook.com or agumaguspelltemple@gmail.com do email him he is a great man. the government is also interested in this DR, thank you for saving my life, and I promise I will always testify for your good work.
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Disease State Presentation: Herpes Simplex Virus

  1. 1. DiseaseHERPES SIMPLEX VIRUS State Presentation Joy A. Awoniyi Pharm.D Candidate 2012 Florida A&M University October 21, 2011 Community Pharmacy Rotation Preceptor: Dr. Kayon Samuels-Dennis
  2. 2. OBJECTIVES THE PURPOSE OF THIS PRESENTATION IS TO: D e f i ne h e r p e s s i m pl e x v i r us P r o v i d e a b a c k g r o und r e g a r d i ng t h e e p i de mi ol o gy a n d m e t h o d s o f t r a n s m i ssi on o f t h e v i r us R e v i e w t h e c o m p l ic a ti o ns a s s o c i a t e d w i t h t h e d i s e a se D i f f e r e n ti a t e b e t w e e n t h e t w o t y p e s o f h e r p e s s i m pl e x v i r use s H i g hl i g ht t h e s i g ns a n d s y m p to m s a s s o c i a t e d w i t h t h e d i a g no si s o f t h e d i se a se D i s ti ng ui sh H S V f r o m o t h e r d i s e a s e s t a t e s w i t h s i m i la r c l i ni ca l p r e s e n t a ti on s P r o v i d e a n o v e rv i e w o f t h e a v a i l a b l e p h a r m a c ol ogi c a l u s e d t o m a n a g e H S V E x p l a i n m o d e s o f p r e v e nti on o f t h e s p r e a d a n d a c q ui si ti o n o f t h e v i r us E m p ha si z e t h e r o l e o f t h e p h a r m a ci s t i n t h e t r e a t m e n t o f p a t i en t s w i t h H S V
  3. 3. HerpesBACKGROUND Simplex Virus
  4. 4. DEFINITION Herpes simplex viruses are host -adapted pathogens that cause a wide variety of disease states Double-stranded DNA viruses characterized by  Neurovirulence – the ability to invade the nervous system  Latency  Reactivation – which can be induced by various stimuli such as fever or emotional stress
  5. 5. EPIDEMIOLOGY By age 30, 50% of those in a high socioeconomic status an 80% in a lower socioeconomic status are seropositive for HSV-1 Lifetime seroprevalence of HSV-2 can be anywhere between 20 – 80% HSV-2 is more common in women (25%) than in men (17%) In the United States, HSV-2 is more prevalent in blacks (45%) as compared to Mexican -Americans (22%) and Whites (17%)
  6. 6. TRANSMISSION Humans are the only natural reservoirs Transmission occurs by close personal contact Infection occurs by way of inoculation of the virus into susceptible mucosal surfaces The virus is inactivated at room temperature and by drying
  7. 7. TYPES OF HERPES SIMPLEX VIRUS HSV-1 HSV-2 Traditionally associated  Traditionally associated with orofacial disease with genital disease Reactivates more  Reactivates 8-10 times frequently in the oral more frequently in the region genital region than the orolabial Usually acquired in  Presence may be an childhood indirect measure of sexual activity, in some cases Transmitted chiefly by contact with infected  Transmitted sexually or saliva from a mothers genital tract infection to her newborn
  8. 8. COMPLICATIONS Bacterial and fungal super -  CNS I nvolvement infections  Aseptic Meningitis  Ganglionitis and myelitis Ocular infections  Herpes Simplex Encephalitis (70% mortality rate untreated)  Conjunctivitis  HSV-2 is more commonly  HSV is the leading infectious associated with CNS infection cause of blindness in the in newborns, HSV-1 in adults United States  Pregnancy complications Skin Infections  Neonatal Infection leading to  Eczema Herpeticum uterine growth retardation and  Herpetic Whitlow (involvement premature births of the fingers)  Herpes gladiatorum: scattered  Neonatal disease HSV 1 lesions observed in wrestlers  Risk of mother to child transmission is 50% Visceral I nfections  I ncreased risk of HIV infection
  9. 9. CLINICAL Herpes SimplexPRESENTATIONS Virus
  10. 10. HERPES SIMPLEX VIRUS TYPE 1 Herpes Labialis  Most common manifestation of recurrent HSV-1 infection  May last up to 5 days and occur in most patients less than twice per year  Sign  Erythematous papules rapidly developing into tiny vesicles that eventually ulcerate  Symptoms  Pain, burning and tingling at the site prior to papule formation
  11. 11. HERPES SIMPLEX VIRUS TYPE 1 Acute Herpetic Gingivostomatits  Primarily seen in younger patients (6 months – 5 years) but may occur more acutely and less severely in adults  Abrupt onset, lasting 5 – 7 days  Signs  High temperatures between 102 and 104 °  Gingivitis is the most striking feature  Vesicular lesions on the oral mucosa, tongue, and lips  Symptoms  Anorexia and listlessness
  12. 12. HERPES SIMPLEX VIRUS TYPE 1 Acute Herpetic Pharyngotonsilitis  Pharyngotonsilitis is seen more often in adults  Signs  Oral and labial lesions occur in less than 10% of patients  Ruptured vesicles may rupture and form ulcerative lesions with gray exudates n the tonsils and posterior pharynx  Fever  Symptoms  Malaise  Headache  Sore throat
  13. 13. PRIMARY (FIRST EPISODE) GENITAL HERPES May be caused by either type of HSV  Clinical features are indistinguishable  Recurrence is more common with HSV-2 Incubation period is anywhere between 1 day to 3 weeks Symptoms  Systemic: Fever, headache, malaise an myalgia  Local: Pain, itching, dysuria, vaginal and urethral discharge, tender lymphadenopathy  Severe and prolonged manifestations  May be asymptomatic Ulcerative lesions persist anywhere from 4 to 15 days. In 75% of patients, new lesions will form in 4 -10 days
  14. 14. PRIMARY GENITAL HERPES Men Vesicles appear in the glans penis and prepuce, or shaft of the penis  May also appear on the scrotum, thighs, and buttocks 30 – 40% of men may experience herpetic urethritis which presents as severe dysuria and mucoid discharge Herpetic proctitis involves the perianal area and rectum and is more commonly involved in those who engage in anal intercourse
  15. 15. PRIMARY GENITAL HERPES Women  Vesicles appear on the external genitalia, labia minora and majora, vaginal vestibule, and introitus  70 – 90% of women experience cervical involvement, which may be ulcerative or necrotic to the mucosa  Cervicitis is the sole manifestation in some women  Dysuria may occur  May cause urinary retention  May be associated with urethritis, which is seen more often with the HSV Type 1
  16. 16. RECURRENT GENITAL HERPES 90% of patients are reactivated with genital herpes within the first 12 months  HSV-2 is reactivated more commonly, with 60%of patients experiencing recurrences within the first year Symptoms  Tenderness, pain, and burning at the site of eruption lasting from 2 hours to 2 days  Fever is uncommon  More severe in women than men The frequency and severity of recurrence decreases with time Lesions generally heal within 8 to 10 days in women, and between 7 and 10 days for men  Infection lasts may last over 30 days in immunocompromised patients
  17. 17. SUBCLINICAL GENITAL HERPES Most primary HSV infections are asymptomatic  70-80% of seropositive individuals have no known history of genital herpes
  18. 18. HerpesDIAGNOSIS Simplex Virus
  19. 19. LABORATORY STUDIES The criteria for standard diagnosis includes isolation of the virus in tissue culture Immunofluorescent  Polymerase Chain staining: Distinguishes Reactions: Detects HSV between types of herpes DNA in clinical specimens simples virus as well as non -  Can also detect herpes viruses asymptomatic viral shedding Tzank Smears: Assists in the  Direct Fluorescent Antigen : diagnosis of cutaneous Staining with fluorescent herpes virus infections, but antibodies may distinguish does not distinguish between types between types
  20. 20. DIFFERENTIAL DIAGNOSES Candidiasis: Fungal infection Chancroid: STD and Cofactor in HIV transmission Hand-foot-and-mouth Disease: transmitted by the fecal - oral route Herpes Zoster (Shingles): Benign course Syphilis: STD with nonspecific manifestations
  21. 21. PHARMACOLOGICAL Herpes Simplex TREATMENTS Virus
  22. 22. MEDICATION THERAPY GOALS Reduce morbidity Prevent complications
  23. 23. HSV THERAPY Antiviral Agents  These agents are nucleoside analogs that are phosphorylated by thymidine kinase to form a nucleoside triphosphate which inhibits HSV polymerase  Mechanism of action:  Interferes with DNA Polymerase to inhibit DNA replication by way of chain termination Only oral agents are recommended for the treatment of genital herpes, while both prescription and over-the counter agents may be used to treat cold sores
  24. 24. RECOMMENDED REGIMENS FOR GENITAL HERPES First Episode Suppressive TherapyRecommendations from the Department of Health and Human Services Centers for Disease Control and Prevention Sexually Transmitted Diseases Guidelines, 2010.
  25. 25. ACYCLOVIR (ZOVIRAX®) Used for both types of HSV Side effects  Malaise  Nausea, vomiting  Pruritus  Acute Renal failure Pregnancy Category B Avoid use with other nephrotoxic drugs as renal failure resulting in death has occurred
  26. 26. ACYCLOVIR (ZOVIRAX®) Adult Dosing Pediatric Dosing Initial Treatment:  Neonatal HSV  200mg PO Q4H 5 times daily x 7-10 days  20mg/kg/day div Q8H  400mg PO TID x 5-10 days IV x 14-21 days Recurrence Treatment  200mg PO Q4H 5times daily  HSV Encephalitis x 5 days  Initiate at the earliest sign or  3 months -12 yrs: symptom of recurrence 20mg/kg Q8H x 10 days Chronic Suppression  12 and older: 10-  400mg PO BID up to 12 15mg/kg IV Q8H x 14-12 months days  200mg 3-5 times daily for up to 12 months
  27. 27. ACYCLOVIR (ZOVIRAX®) FormulationsFormulation Unit Count Estimated PriceGeneric 200mg Capsules 30 $10 - 20Generic 200mg/5mL Oral 473 mL $10 - 20SuspensionGeneric 400mg Tablets 60 tabs $20 - 40Generic 800mg Tablets 30 tabs $20 - 40Brand 200mg Capsules 30 caps $20 - 40Brand 200mg/5mL Oral Suspension 473 mL $100 - 150Brand 400mg Tablets 60 tabs $100 - 150Brand 800mg Tablets 30 tabs $100 - 150Generic Powder for injection 500mg and 1g vials --------------------Generic IV solution 50mg/mL multiple --------------------
  28. 28. ACYCLOVIR TOPICAL (ZOVIRAX® OINTMENT OR CREAM) IMPORTANT NOTE: This formulation has no clinical benefit for recurrent genital herpes and is ineffective against herpes labialis Recommended Adult Dose for INITIAL OCCURRENCE:  Apply Q3H 6 times daily x 7 days  Start therapy at the earliest sign or symptom of infectionFormulation Unit Count Estimated PriceBrand 5% Cream 1 tube, 2 grams $100Brand 5% Cream 1 tube, 5 grams $180Brand 5% Ointment 1 tube, 15 grams $60-100Brand 5% Ointment 1 tube, 3 grams $20-40
  29. 29. ACYCLOVIR AND HYDROCORTISONE (XERESE®) Used to treat herpes labialis in patients over 12 years Recommended Adult Dose:  Apply 5 times daily x 5 days  Start therapy at the earliest sign or symptom of infection May cause pigment changes
  30. 30. FAMCICLOVIR (FAMVIR®) Used for both types of HSV Dose renally when CrCl is less than 60mL/min due to risk of acute renal failure Side effects  Headache  Nausea  Fatigue  Fever Pregnancy Category B Pro-drug that is biotransformed into its active metabolite, Penciclovir
  31. 31. FAMCICLOVIR (FAMVIR®) Adult Dosing Pediatric Dosing Recurrent Herpes Labialis  Safety and efficacy  1500mg PO once has not been established in this Primary Genital HSV population, but the  250mg PO TID x 5-10 days medication is used off-  Off-label indication label in adolescents Recurrent Genital HSV  1000mg PO BID x 1 day  Primary Genital HSV  HIV Patients: 500mg PO BID  250 mg PO TID x 7-10days x 7days  Chronic Suppression Chronic Suppression  125-250 mg PO BID up to  250mg PO BID up to 12 12 months months
  32. 32. FAMCICLOVIR (FAMVIR®) FormulationsFormulation Unit Count Estimated PriceGeneric 125mg Tablets 30 tabs $160Generic 250mg Tablets 30 tabs $170Generic 500mg Tablets 30 tabs $330Brand 125mg Tablets 30 tabs $200Brand 250mg Tablets 30 tabs $216Brand 500mg Tablets 30 tabs $450
  33. 33. PENCICLOVIR (DENAVIR®) Used topically for  Adult Dosing Herpes Labialis  Apply Q2H x 4 days  No pediatric dosing Side effects information  Headache available  Taste changes  Erythema  Pruritus Formulation Unit Estimated Price Pregnancy Count Category B Brand name 1 tube $100 1% cream (1.5g)
  34. 34. VALACYCLOVIR (VALTREX®) Used for both types of HSV Provides an advantage as it reduces the risk of heterosexual transmission of genital herpes to susceptible partners when used as suppressive therapy M ore expensive pro -drug of A cyclovir, with more convenient dosing Side effects  Abdominal pain  Headache  Nausea  Depression Pregnancy Category B Renal dosing is required when creatinine cl earance is l ess than 50mL/min
  35. 35. VALACYCLOVIR(VALTREX®) Adult Dosing Pediatric Dosing Recurrent Herpes  Safety and efficacy Labialis  2 PO Q12H x 1 day has not been established in this Primary Genital HSV population  1g PO BID x 10days Recurrent Genital HSV  500mg PO BID x 3 days Chronic Suppression  1 g PO Daily  500mg PO BID if HIV- infected
  36. 36. VALACYCLOVIR (VALTREX®) FormulationsFormulation Unit Count Estimated PriceGeneric 1g Tablets 30 tabs $350Generic 500mg Tablets 30 tabs $170Brand 1g Tablets 30 tabs $370Brand 500 mg Tablets 30 tabs $240
  37. 37. DOCOSANOL (ABREVA®) Available over the counter for the treatment of herpes labialis Mechanism of Action:  Inhibits the fusion of the herpes simplex virus envelope with host cell plasma membranes. This results in the inhibition of viral entry into cells and subsequent viral replication Side effects  HSV development outside the treatment area  Headache  Application site reactions Recommended dosing  Apply topically to cover all lesions 5 times daily until healed (Maximum of 10 days)
  38. 38. TOPICAL OVER-THE-COUNTER AGENTS FOR HERPES LABIALIS The following medications may be recommended over the counter for the treatment of cold sores in individuals older than 2 years and are applied as needed for a maximum of 4 days Anbesol Cold Sore  Orajel Cold Sore Swabs  Benzocaine, Camphor,  Benzocaine Topical allantoin, Petrolatum Topical  Orajel Cold Sore Brush or Neosporin LT Lip Multi-Action cold sore treatment  Benzocaine, allatoin, dimethicone, petrolatum  Pramoxine/ allantoin topical topical  Zilactin Cold Sore Gel or Orajel Overnight Cold Solution Sore Patch  Benzoyl Alcohol Topical  Dyclonine Topical
  39. 39. PREVENTION AND Herpes Simplex FOLLOW-UP Virus
  40. 40. PREVENTION Latex condoms are recommended to minimize exposure to genital herpes infections  Ulcers may occur outside of the condom, and transmission is still possible Herpetic whitlow can be avoided by the use of latex gloves when inserting the hand into an oral cavity Daily antiviral therapy can be given to reduce episodes of asymptomatic viral shedding
  41. 41. PHARMACISTS ROLE  Compliance  Encourage adherence to medication regimens to decrease transmissions  Check to see if patients are keeping physician appointments  Identify barriers to medication adherence  Counseling  Give unbiased clinical advise on OTC treatments  Educate patients on the modes of transmission  Encourage patients with genital herpes to inform sexual partners regarding their diagnosis’
  42. 42. REFERENCES C e n t e r s f o r D i s e as e C o n t r o l an d P r e v e n ti o n. “ G e n i t al HS V I n f e c tio n s”. M M W R 2 0 1 0 ;5 9 (No . R R - 1 2 ): 2 0 - 2 4 . K i m b e rl i n D Q , R o u s e D J . C l i n i cal P r ac t i c e . G e n i t al He r p e s . N E n g l J Me d . M ay 6 2 0 0 4 ;3 5 0 (1 9 ):1 9 7 0 - 7 7 . Nag o t N, O u e d r ao go A , F o u l o n g n e V, e t al . R e d u c t i o n o f HI V - 1 R NA l e v el s w i t h t h e r ap y t o s u p p r e s s h e r p e s s i m p l e x v i r us . N E n g l J Me d . 2 0 0 7 ;3 5 6 (8 ):7 9 0 - 9 9 . A r d ui n o P G , P o r t e r S R . O r al an d p e r i o r al h e r p e s s i m p l e x v i r us t y p e 1 (HS V - 1 ) i n f e c t i o n : r e v i e w o f i t s m an ag e m e n t . S al v agg i a M R . “ He r p e s S i m p l e x ”. M e d s c ap e R e f e r e n c e . A v ai l abl e at : h t t p ://e m e dici n e .m e dsc ap e.c o m /articl e / 2 1 8 5 8 0 . A c c e s s e d o n 1 7 O c t 2 0 1 1 . L as t u p d at e d 3 D e c 2 0 1 0 . “ A n ti v iral ag e n t s f o r t h e t r e at m e n t o f c o m m o n h e r p e t i c i n f e c t i on s i n i m m u n o c o m p e te n t p at i e n t s”. P h ar m ac i s t’s L e t t e r 2 0 0 2 ; 1 8 (1 0 ):1 8 1 0 0 7 .

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