Curbing recurrences: Combination treatments help patients with recurrent genital herpes

November 1, 2009

Recurrent genital herpes infections can be challenging to treat, and patients' quality of life decreases as frequency of relapses increases.

Key Points

Moscow - The incidence of genital herpes (GH) is on the rise, and frequent recurrences of the infection can drastically decrease the quality of life (QoL) in affected patients. A recent study shows that in those patients who suffer from multiple recurrences of genital herpes, a combination treatment with nucleoside analogues and selective serotonin reuptake inhibitors (SSRI) can lead to a decrease in the frequency of recurrences of the viral infection, and, according to one expert, may provide solutions for the long-term management of this patient population.

The dawn of acyclovir and other nucleoside analogues has brought much relief to patients suffering from herpes simplex virus (HSV) infections, among other viral diseases, particularly genital herpes. However, these nucleoside analogues are not enough to thwart the frequent recurrences of the disease when treatment is stopped. These recurrences may cause considerable distress and anxiety in the affected patient.

"Some unfortunate patients are plagued with recurrent GH infections, leading to the development of psycho-emotional and depressive disorders, which, in some cases, can even result in suicide," says Gulnara Taldibaeva, M.D., Central Research Institute for Skin and Venereal Diseases, Moscow. "The problem is not so much that the antiviral medications are ineffective in this population, but that patients with multiple recurrences become so laden with anxiety and exquisitely fearful of their next recurrence and the probability to infect their partner that this great psychological pressure makes them even more susceptible to even quicker recurrences."

Dr. Taldibaeva and her colleagues from Moscow State University for Medicine and Dentistry recently conducted a clinical study investigating the therapeutic effect of a combination therapy of SSRI and nucleoside analogues in patients suffering from recurrent GH infections, and evaluated the improvement in the health-related QoL of the patients. In the study, 73 patients who frequently suffered recurrent GH infections (from six to 10 times a year) received valacyclovir (500 mg, twice daily for five days) during clinical recurrences of GH. Patients with depressive disorders also received antidepressant sertraline from the SSRI group (50 mg, once daily, orally for 24 weeks). Health-related QoL was measured using MOS-SF-36 survey (normal values for the scale are >50), and all patients were consulted and evaluated for psychiatric disease by a psychiatrist at baseline and throughout the study. Patients were followed up for a total of six months.

Study results

Results showed that the scores for six out of eight domains of the MOS-SF-36 were significantly lower in those respondents who were most psychologically and sexually disturbed by their GH recurrences and who also found it difficult to discuss the problem with their partner. However, after the 24-week sertraline therapy was started, the mental status normalized in 52 patients (71.2 percent). Dr. Taldibaeva noticed that there were only two recurrences of GH in the first and second month of treatment, and no recurrences for the next four months in these 52 patients. The study also found that the scores of the estimated QoL rose to >80 in 70 out of 73 patients (95.8 percent).

A new reality

"Many patients with recurrent herpes of more than six to 10 times a year become very apprehensive and even scared to have normal sexual relations with their partner.

"They become generally fearful and almost 'wait' for the recurrence to occur, as they are convinced that a recurrence is inevitable. This new 'reality' for them is very difficult to handle, and they suffer greatly under this strain," Dr. Taldibaeva says.

Psychiatric evaluations

The psychiatric evaluations of the patients in the study revealed that patients were depressed because of the fear of infection and recurrence of their disease. According to Dr. Taldibaeva, the frequency of the recurrences leads to stress, which in turn causes depression in these patients.

This depression can then help cause recurrence of GH infections, leading to a vicious circle and psychosomatic disease.

Some of the patients in the study had periods of recurrences as frequent as once a week or every two weeks. However, after the combination therapy, this frequency decreased.

"The administration of only antiviral therapy is usually ineffective in keeping recurrences to a minimum if the therapy is not suppressive, especially in patients who have six recurrences or more a year. Furthermore, any physical or mental stress can open the door for recurrence and serve as a trigger for the recurrence. Therefore, a combination therapy is warranted, instead of just treating the viral infection itself," Dr. Taldibaeva says.

Dr. Taldibaeva suggests that those patients with six recurrences or more a year should take suppressive antiviral therapy such as 500 mg valacyclovir once daily, orally, for three months. But those patients who suffer depressions, as seen for example in a high score of the HAM-D (Hamilton Rating Scale for Depression), should take a combination therapy of antidepressants for 24 weeks and antiviral therapy for episodic treatment of their HSV infection.

"After a combination therapy with valacyclovir and an antidepressant, it would be wise for the patient to continue with the antidepressant medication until their psyche returns to normal and use valacyclovir only for episodic recurrences," Dr. Taldibaeva says.