Acyclovir (Systemic) - Pediatric Drug Information - UpToDate PDF

16.04.
2020 Acyclovir (systemic): Pediatric drug information - UpToDate
Official reprint from UpToDate®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.
Acyclovir (systemic): Pediatric drug information
Copyright 1978-2020 Lexicomp, Inc. All rights reserved.
(For additional information see "Acyclovir (systemic): Drug information" and see "Acyclovir (systemic): Patient drug
information")
For abbreviations and symbols that may be used in Lexicomp (show table)
Brand Names: US
Zovirax
Brand Names: Canada

APO-Acyclovir; MYLAN-Acyclovir; RATIO-Acyclovir [DSC]; TEVA-Acyclovir; Zovirax
Therapeutic Category
Antiviral Agent, Oral; Antiviral Agent, Parenteral
Dosing: Neonatal
HSV infection, treatment: Duration: CNS and disseminated infections: At least 21-day
treatment duration; skin and mucous membrane infections: 14-day treatment duration
(Bradley 2015; CDC [Workowski 2015]; AAP [Kimberlin 2013]; Red Book [AAP] 2015):
Body weight <1 kg (Bradley 2015):
PNA ≤14 days: IV: 20 mg/kg/dose every 12 hours
PNA 15 to 28 days: IV: 20 mg/kg/dose every 8 hours
Body weight 1 to 2 kg (Bradley 2015):
PNA ≤7 days: IV: 20 mg/kg/dose every 12 hours
PNA 8 to 28 days: IV: 20 mg/kg/dose every 8 hours
Body weight >2 kg: IV: 20 mg/kg/dose every 8 hours (AAP [Kimberlin 2013]; Bradley
2015; CDC [Workowski 2015]; Red Book [AAP 2015])
HSV, chronic suppression following any HSV infection:

https://www.uptodate.com/contents/acyclovir-systemic-pediatric-drug-information/print?search=aciclovir children&source=panel_search_result&s… 1/34
16.04.2020 Acyclovir (systemic): Pediatric drug information - UpToDate
AAP Recommendation (low dose, 6-month course): Oral: 300 mg/m2/dose every 8 hours
for 6 months; begin after completion of a 14- to 21-day course of IV therapy dependent
upon type of infection (AAP [Kimberlin 2013]; Kimberlin 2011; Red Book [AAP 2015])
Alternate dosing (high-dose, 2-year course) in infants with disseminated or CNS infection
(Tiffany 2005): Limited data available: Oral: Begin after completion of a 21-day course of
IV therapy; dosing based on a prospective trial of 16 consecutive neonates (GA:
Premature: n=4; term=12; age at treatment: Neonate: n=14; PNA >30 days: n=1)
following disseminated or CNS infection; pharmacokinetic data were used to determine
dosing regimen to maintain serum acyclovir concentration above target of 2 mcg/mL;
treatment was continued for 2 years in 14 of 16 patients; results showed normal
neurodevelopmental outcomes in 69% and normal motor development in 70%; no
untoward effects were reported during the study duration.
Initial dosing: Approximate dose: 1,200 to 1,600 mg/m2/dose twice daily
Preterm neonate: Proportional decrease of full-term initial dose
Full term or near term: 400 mg twice daily
Maintenance dosing: In the trial, serum acyclovir concentrations were evaluated to

assess adequacy of dosing to maintain serum concentrations above the target of 2
to 3 mcg/mL. Samples were collected 1 hour after a witnessed dose; if the acyclovir
serum concentration approached or was below the target, the dose was increased to
the next greater 200 mg increment. Serum concentrations were evaluated every 3
months; in order to limit the phlebotomy losses, follow-up serum concentrations were
not evaluated outside of routine monitoring.
Varicella (chickenpox), treatment: IV: 10 to 15 mg/kg/dose every 8 hours for 5 to 10 days;

continue for ≥48 hours after the last new lesions have appeared (Ogilvie 1998; Sauerbrei
2007; Smith 2009)
Dosing adjustment in renal impairment: IV:
>50 mL/minute/1.73 m2: No adjustments necessary
25 to 50 mL/minute/1.73 m2: Administer the usual recommended dose every 12 hours
10 to <25 mL/minute/1.73 m2: Administer the usual recommended dose every 24 hours
<10 mL/minute/1.73 m2: Administer 50% of the usual recommended dose every 24 hours
(eg, if the usual recommended dose is 10 mg/kg/dose every 8 hours, administer 5
mg/kg/dose every 24 hours)
Dosing: Pediatric
Note: Obese patients should be dosed using ideal body weight. Parenteral IV doses >15
mg/kg/dose or 500 mg/m2 may be associated with an increased risk of nephrotoxicity; close
monitoring of renal function is recommended (Rao 2015).
CMV prophylaxis: Low-risk allogeneic hematopoietic stem cell transplant (HSCT) in

seropositive recipient. Note: Begin at engraftment and continue to day 100; requires
close monitoring for CMV reactivation (due to weak activity); not for use in patients at
high risk for CMV disease (Tomblyn 2009):
Oral:
Infants, Children, and Adolescents <40 kg: 600 mg/m2/dose 4 times daily;
maximum dose: 800 mg/dose
Children and Adolescents ≥40 kg: 800 mg 4 times daily
IV: Infants, Children, and Adolescents: 500 mg/m2/dose every 8 hours
Herpes zoster, acute retinal necrosis, treatment (HIV-exposed/-positive):
Initial treatment: IV: Note: Follow up IV therapy with oral acyclovir or valacyclovir
maintenance therapy.
Infants: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS [pediatric]

2013)
Children: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS [pediatric]

2013)
Adolescents: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS

[adult] 2015)
Maintenance treatment; begin after 10- to 14-day course of IV acyclovir: Oral: Infants
and Children: 20 mg/kg/dose 4 times daily for 4 to 6 weeks (DHHS [pediatric] 2013)
Herpes zoster (shingles), treatment:
Immunocompetent host:
Ambulatory therapy: Oral: Children ≥12 years and Adolescents: 800 mg every 4
hours (5 doses per day) for 5 to 7 days (Red Book [AAP 2015])
Hospitalized patient: IV:
Infants: 10 mg/kg/dose every 8 hours for 7 to 10 days (Red Book [AAP

2015])

Children and Adolescents: 500 mg/m2/dose every 8 hours for 7 to 10 days;

some experts recommend 10 mg/kg/dose every 8 hours (Red Book [AAP
2015])
Immunocompromised host (non-HIV-exposed/-positive): IV: Infants, Children, and

Adolescents: 10 mg/kg/dose every 8 hours for 7 to 10 days (Red Book [AAP 2015])
HIV-exposed/-positive:
Mild, uncomplicated disease and no or moderate immune suppression: Oral:
Infants and Children: 20 mg/kg/dose 4 times daily for 7 to 10 days;

maximum dose: 800 mg/dose; consider longer course if resolution of
lesions is slow (DHHS [pediatric] 2013)
Adolescents: 800 mg 5 times daily for 7 to 10 days, longer if lesions resolve

slowly (DHHS [adult] 2015)
Severe immune suppression or complicated disease; trigeminal nerve

involvement, extensive multidermatomal zoster or extensive cutaneous lesions
or visceral involvement: IV:
Infants: 10 mg/kg/dose every 8 hours until resolution of cutaneous lesions

and visceral disease clearly begins, then convert to oral therapy to
complete a 10- to 14-day total course of therapy (DHHS [pediatric] 2013)
Children: 10 mg/kg/dose or 500 mg/m2/dose every 8 hours until resolution

of cutaneous lesions and visceral disease clearly begins, then convert to
oral therapy to complete a 10- to 14-day total course of therapy (DHHS
[pediatric] 2013)
Adolescents: 10 to 15 mg/kg/dose every 8 hours until clinical improvement

is evident, then convert to oral therapy to complete a 10- to 14-day total
course of therapy (DHHS [adult] 2015)
HSV neonatal infection, treatment and suppressive therapy in very young infants
(independent of HIV status):
Treatment (disseminated, CNS, or skin, eye, or mouth disease): Infants 1 to 3

months: IV: 20 mg/kg/dose every 8 hours; treatment duration: For cutaneous and
mucous membrane infections (skin, eye, or mouth): 14 days; for CNS or
disseminated infection: 21 days (AAP [Kimberlin 2013]; Bradley 2015; CDC
[Workowski 2015]; DHHS [pediatric] 2013; Red Book [AAP 2015])
Chronic suppressive therapy following any neonatal HSV infection:

AAP Recommendation (low dose, 6-month course): Infants: Oral: 300

mg/m2/dose every 8 hours for 6 months; begin after completion of a 14- to 21-
day-course of IV therapy dependent upon type of infection (AAP [Kimberlin
2013]; Kimberlin 2011; Red Book [AAP 2015])
Alternate dosing (high dose, 2-year course) in infants with disseminated or CNS
infection (Tiffany 2005): Limited data available: Infants and Children <3 years:
Oral: Begin after completion of a 21-day course of IV therapy; dosing based on
a prospective trial of 16 consecutive neonates (GA: Premature: n=4; term=12;
age at treatment: Neonate: n=14; PNA >30 days: n=1) following disseminated or
CNS infection; pharmacokinetic data were used to determine dosing regimen to
maintain serum acyclovir concentration above target of 2 to 3 mcg/mL;
treatment was continued for 2 years in 14 of 16 patients; results showed normal
neurodevelopmental outcomes in 69% and normal motor development in 70%;
no untoward effects were reported during the study duration.
Initial dosing: 400 mg twice daily; approximate dose: 1,200 to 1,600

mg/m2/dose twice daily
Maintenance dosing: Note: Approximate doses for patients born at term:
Infants 1 to <5 months: 400 mg twice daily
Infants 5 to <9 months: 600 mg twice daily
Infants and Children 9 to <15 months: 800 mg twice daily
Children 15 to 24 months: 1,000 mg twice daily
Note: In the trial, serum acyclovir concentrations were evaluated to

assess adequacy of dosing to maintain serum concentrations above
the target of 2 to 3 mcg/mL. Samples were collected 1 hour after a
witnessed dose; if the acyclovir serum concentration approached or
was below the target, the dose was increased to the next greater 200
mg increment. Maximum dose: 1,200 mg. Serum concentrations were
evaluated every 3 months; in order to limit the phlebotomy losses,
follow-up serum concentrations were not evaluated outside of routine
monitoring.
HSV encephalitis, treatment:
Infants and Children 3 months to <12 years:
Non-HIV-exposed/-positive: IV: 10 to 15 mg/kg/dose every 8 hours for 14 to 21

days. Note: Due to increased risk of neurotoxicity and nephrotoxicity, higher
doses (20 mg/kg) are not recommended (Red Book [AAP 2015]).
HIV-exposed/-positive: IV: 10 mg/kg/dose every 8 hours for 21 days; higher

doses (up to 20 mg/kg) may be necessary (DHHS [pediatric] 2013)
Children ≥12 years and Adolescents (independent of HIV status): IV: 10 mg/kg/dose
every 8 hours for 14 to 21 days (Red Book [AAP 2015)]
HSV genital infection:
First infection, mild to moderate:
Non-HIV-exposed/-positive:
Children <12 years: Oral: 40 to 80 mg/kg/day divided in 3 to 4 doses per

day for 5 to 10 days; maximum daily dose: 1,200 mg/day (Bradley 2015;
Red Book [AAP 2015])
Children and Adolescents ≥12 years: Oral: 200 mg every 4 hours while
awake (5 times daily) or 400 mg 3 times daily for 7 to 10 days; treatment
can be extended beyond 10 days if healing is not complete (CDC
[Workowski 2015]; Red Book [AAP 2015])
Children: Oral: 20 mg/kg/dose 3 times daily for 7 to 10 days; maximum

dose: 400 mg/dose (DHHS [pediatric] 2013)
Adolescents: Oral: 400 mg 3 times daily for 5 to 14 days (DHHS [adult]

2015)
First infection, severe (independent of HIV status): IV: Children and Adolescents ≥12
years: 5 mg/kg/dose every 8 hours for 5 to 7 days or 5 to 10 mg/kg/dose every 8
hours for 2 to 7 days, followed with oral therapy to complete at least 10 days of
therapy (CDC [Workowski 2015]; Red Book [AAP 2015])
Recurrent infection:
Children <12 years (independent of HIV status): Oral: 20 mg/kg/dose 3 times

daily for 5 days; maximum dose: 400 mg/dose (Bradley 2015; DHHS [pediatric]
2013)
Children and Adolescents ≥12 years:
Non-HIV-exposed/-positive: Oral: 200 mg every 4 hours while awake (5

times daily) for 5 days, or 400 mg 3 times daily for 5 days, or 800 mg twice

daily for 5 days or 800 mg 3 times daily for 2 days (CDC [Workowski 2015];
Red Book [AAP 2015])
HIV-exposed/-positive: Adolescents: Oral: 400 mg 3 times daily for 5 to 14

days (DHHS [adult] 2015)
Suppression, chronic:
Non-HIV-exposed/-positive:
Children <12 years: Limited data available: Oral: 20 mg/kg/dose twice daily;
maximum dose: 400 mg/dose (Bradley 2015)
Children and Adolescents ≥12 years: Oral: 400 mg twice daily; reassess
therapy after 12 months (CDC [Workowski 2015]; Red Book [AAP 2015])
Infants and Children: Oral: 20 mg/kg/dose twice daily; maximum dose: 800
mg/dose (DHHS [pediatric] 2013)
Adolescents: Oral: 400 mg twice daily (DHHS [adult] 2015)
HSV gingivostomatitis:
Non-HIV-exposed/-positive: Primary infection:
AAP recommendations: Children and Adolescents: Oral: 20 mg/kg/dose 4 times

daily for 5 to 7 days; usual maximum dose: 200 mg/dose, others have reported
higher (400 mg/dose) (Bradley 2015; Cernik 2008; Red Book [AAP 2015])
Alternate dosing: Infants ≥10 months, Children, and Adolescents: Oral: 15

mg/kg/dose five times daily for 7 days; maximum dose: 200 mg/dose (Amir
1997; Balfour 1999); dosing based on a placebo controlled trial in children 1 to 6
years of age (n=72, treatment group: n=31); results showed when treatment
started within 72 hours of symptom onset a shorter duration of symptoms and
viral shedding was observed (Amir 1997)
HIV-exposed/-positive (DHHS [pediatric] 2013):
Mild, symptomatic: Oral: Infants and Children: 20 mg/kg/dose 4 times daily for 7
to 10 days; maximum dose: 400 mg/dose
Moderate to severe, symptomatic: IV: Infants and Children: 5 to 10 mg/kg/dose

every 8 hours; switch to oral therapy once lesions begin to regress
HSV, herpes labialis (cold sore) (HIV-exposed/-positive): Treatment:

Infants and Children: Oral: 20 mg/kg/dose 4 times daily for 5 days; maximum dose:
400 mg/dose (DHHS [pediatric] 2013)
Adolescents: Oral: 400 mg 3 times daily for 5 to 10 days (DHHS [adult] 2015)
HSV, herpes labialis (cold sore) recurrent, chronic suppressive therapy:

Immunocompetent Children and Adolescents: Oral: 10 mg/kg/dose 3 times daily;
maximum daily dose: 1,000 mg/day; reevaluate after 12 months (Red Book [AAP 2015])
HSV mucocutaneous infection:
Immunocompetent host: Infants, Children, and Adolescents:
Treatment (Bradley 2015):
IV: 5 mg/kg/dose every 8 hours
Oral: 20 mg/kg/dose 4 times daily for 5 to 7 days; maximum dose: 800

mg/dose
Suppression, chronic: Limited data available; no pediatric data; some experts

recommend oral 20 mg/kg/dose 2 to 3 times daily for 6 to 12 months, then
reevaluate need; maximum dose: 400 mg/dose (Bradley 2015)
Immunocompromised host:
Treatment:
IV:
Infants and Children: 10 mg/kg/dose every 8 hours for 7 to 14 days

(Red Book [AAP 2015])
Adolescents: 5 to 10 mg/kg/dose every 8 hours; change to oral therapy

after lesions begin to regress (DHHS [adult] 2015; Red Book [AAP
2015])
Oral: Children ≥2 years and Adolescents: 1,000 mg/day in 3 to 5 divided

doses for 7 to 14 days; some suggest the maximum daily dose should not
exceed 80 mg/kg/day (Red Book 2009; Red Book [AAP 2015])
Suppression, chronic (cutaneous, ocular) episodes:
Infants and Children (HIV-exposed/-positive): Oral: 20 mg/kg/dose twice

daily; maximum dose: 800 mg/dose; reassess after 12 months (DHHS
[pediatric] 2013)

Children 12 years of age (non-HIV-exposed/-positive): Prevention of ocular

episodes: Oral: 400 mg twice daily; reassess at 12 months (Red Book [AAP
2015])
Adolescents (independent of HIV status): Oral: 400 mg twice daily;

reassess at 12 months (DHHS [adult] 2015; Red Book [AAP 2015])
HSV progressive or disseminated infection, treatment (immunocompromised

host):
Non-HIV-exposed/-positive: Infants, Children, and Adolescents: IV: 10 mg/kg/dose

every 8 hours for 7 to 14 days (Red Book [AAP 2015])
HIV-exposed/-positive: Infants, Children, and Adolescents: IV: 10 mg/kg/dose every

8 hours for 21 days; higher doses (up to 20 mg/kg/dose) may be used in children
<12 years of age (DHHS [pediatric] 2013; Red Book [AAP 2015])
HSV, acute retinal necrosis, treatment (HIV-exposed/-positive): Children (DHHS

[pediatric] 2013):
Initial treatment: IV: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days. Note:

Follow up IV therapy with oral acyclovir or valacyclovir maintenance therapy.
Maintenance treatment: Begin after 10- to 14-day course of IV acyclovir: Oral: 20

mg/kg/dose 4 times daily for 4 to 6 weeks
HSV prophylaxis; immunocompromised hosts, seropositive:
Hematopoietic stem cell transplant (HSCT) in seropositive recipient (Tomblyn 2009):
Prevention of early reactivation: Note: Begin at conditioning and continue until

engraftment or resolution of mucositis; whichever is longer (~30 days post-
HSCT)
Infants, Children, and Adolescents <40 kg:
IV: 250 mg/m2/dose every 8 hours or 125 mg/m2/dose every 6 hours;

maximum daily dose: 80 mg/kg/day
Oral: 60 to 90 mg/kg/day in 2 to 3 divided doses; maximum dose: 800

mg/dose twice daily
Children and Adolescents ≥40 kg:
IV: 250 mg/m2/dose every 12 hours
Oral: 400 to 800 mg twice daily

Prevention of late reactivation: Note: Treatment during first year after HSCT.
Infants, Children, and Adolescents <40 kg: Oral: 60 to 90 mg/kg/day in 2 to

3 divided doses; maximum daily dose: 800 mg twice daily
Children and Adolescents ≥40 kg: Oral: 800 mg twice daily
Other immunocompromised hosts who are HSV seropositive:
IV: Infants, Children, and Adolescents: 5 mg/kg/dose every 8 hours during

period of risk (Red Book [AAP 2015])
Oral: Children ≥2 years and Adolescents: 200 mg every 4 hours while awake (5
doses daily) or 200 mg every 8 hours; administer during periods of risk (Red
Book [AAP 2015])
Varicella (chickenpox) or Herpes zoster (shingles), prophylaxis
Hematopoietic stem cell transplant (HSCT): Prophylaxis of disease reactivation:

Note: Continue therapy for 1 year after HSCT (Tomblyn 2009):
Infants, Children, and Adolescents <40 kg: Oral: 60 to 80 mg/kg/day in 2 to 3

divided doses
Children and Adolescents ≥40 kg: Oral: 800 mg twice daily
HIV-exposed/-positive: Limited data available: Note: Consider use if >96 hours

postexposure or if VZV-immune globulin is not available; begin therapy 7 to 10 days
after exposure; some experts begin therapy at first appearance of rash (DHHS
[pediatric] 2013).
Infants and Children: Oral: 20 mg/kg/dose 4 times daily for 7 days; maximum
dose: 800 mg/dose (DHHS [pediatric] 2013)
Adolescents: Oral: 800 mg 5 times daily for 5 to 7 days (DHHS [adult] 2015)
Other immunocompromised hosts: Infants, Children, and Adolescents: Oral: 20

mg/kg/dose 4 times daily for 7 days; maximum dose: 800 mg/dose. Note: Consider
use if VZV-immune globulin or IVIG is not available; begin therapy 7 to 10 days after
exposure (Red Book [AAP] 2015).
Varicella (chickenpox), treatment: Begin treatment within the first 24 hours of rash
onset:
Immunocompetent host:
https://www.uptodate.com/contents/acyclovir-systemic-pediatric-drug-information/print?search=aciclovir children&source=panel_search_result&… 10/34

Ambulatory therapy: Oral: Children ≥2 years and Adolescents: 20 mg/kg/dose 4

times daily for 5 days; maximum daily dose: 3,200 mg/day (Red Book [AAP
2015])
Hospitalized patient: IV: Infants, Children, and Adolescents: 10 mg/kg/dose or

500 mg/m2/dose every 8 hours for 7 to 14 days (Bradley 2015; Red Book [AAP
2015]); some experts recommend 15 to 20 mg/kg/dose for severe disseminated
or CNS infection (Bradley 2015)
Immunocompromised host (non-HIV-exposed/-positive): IV:
Infants: 10 mg/kg/dose every 8 hours for 7 to 10 days (Red Book [AAP 2015])
Children and Adolescents: 500 mg/m2/dose every 8 hours for 7 to 10 days;

some experts recommend 10 mg/kg/dose every 8 hours (Red Book [AAP 2015])
Mild, uncomplicated disease and no or moderate immune suppression: Oral:
Infants and Children: 20 mg/kg/dose 4 times daily for 7 to 10 days and until
no new lesions for 48 hours; maximum dose: 800 mg/dose (DHHS
[pediatric] 2013)
Adolescents: 800 mg 5 times daily for 5 to 7 days (DHHS [adult] 2015)
Severe, complicated disease or severe immune suppression: IV:
Infants: 10 mg/kg/dose every 8 hours for 7 to 10 days and until no new

lesions for 48 hours (DHHS [pediatric] 2013)
Children: 10 mg/kg/dose or 500 mg/m2/dose every 8 hours for 7 to 10 days

or until no new lesions for 48 hours (DHHS [pediatric] 2013)
Adolescents: 10 to 15 mg/kg/dose every 8 hours for 7 to 10 days; may

convert to oral therapy after defervescence and if no evidence of visceral
involvement is evident (DHHS [adult] 2015)
Dosing: Renal Impairment: Pediatric
Monitor closely for neurotoxicity (Chowdhury 2016).
Infants, Children and Adolescents: IV:
CrCl >50 mL/minute/1.73 m2: No dosage adjustment necessary

CrCl 25 to 50 mL/minute/1.73 m2: Administer the usual recommended dose every 12

hours
CrCl 10 to <25 mL/minute/1.73 m2: Administer the usual recommended dose every
24 hours
CrCl <10 mL/minute/1.73 m2: Administer 50% of the usual recommended dose every
24 hours (eg, if the usual recommended dose is 10 mg/kg/dose every 8 hours, then
administer 5 mg/kg/dose every 24 hours)
Intermittent hemodialysis (IHD): Dialyzable (60% reduction following a 6-hour

session): 5 mg/kg/dose every 24 hours; administer after hemodialysis on dialysis
days (Aronoff 2007)
Peritoneal dialysis (PD): 5 mg/kg/dose every 24 hours; no supplemental dose

needed (Aronoff 2007)
Continuous renal replacement therapy (CRRT): 10 mg/kg/dose every 12 hours

(Aronoff 2007)
Dosing: Hepatic Impairment: Pediatric

There are no dosage adjustments provided in the manufacturer's labeling.
Dosing: Adult
(For additional information see "Acyclovir (systemic): Drug information")
Bell palsy, new onset (adjunctive therapy) (alternative agent) (off-label use): Oral: 400
mg 5 times daily for 10 days in combination with corticosteroids; begin within 3 days of
symptom onset. Note: Antiviral therapy alone is not recommended (AAN [Gronseth 2012];
AAO-HNSF [Baugh 2013]; Ronthal 2018); some experts only recommend addition of an
antiviral to steroid therapy in patients with severe Bell palsy (de Almeida 2014).
Cytomegalovirus (CMV), prevention in low-risk allogeneic hematopoietic cell transplant

(HCT) recipients (alternative agent) (off-label use): Note: Begin at engraftment and
continue to day 100; requires close monitoring for CMV reactivation (due to weak activity); not
for use in patients at high risk for CMV disease (ASBMT/IDSA [Tomblyn 2009]):
IV: 500 mg/m2/dose every 8 hours for up to 4 weeks or until hospital discharge, followed
by oral therapy (ASBMT/IDSA [Tomblyn 2009]; Boeckh 2009; Ljungman 2002)
Oral: Following initial IV therapy: 800 mg 4 times daily (ASBMT/IDSA [Tomblyn 2009];
Boeckh 2009; Ljungman 2002)

Herpes simplex virus (HSV), central nervous system infection (encephalitis or

meningitis): IV: 10 mg/kg/dose every 8 hours. Duration for encephalitis is 14 to 21 days and
for meningitis is 10 to 14 days; treatment of encephalitis requires IV therapy while treatment
of meningitis may include step-down oral antiviral therapy. Note: Empiric HSV therapy should
be initiated in all patients with suspected encephalitis (IDSA [Tunkel 2008]; Tunkel 2018;
Wilck 2013).
Herpes simplex virus, mucocutaneous infection:
Esophagitis (off-label use):
Immunocompetent patients: Oral: 400 mg 3 times daily or 200 mg 5 times daily for 7
to 10 days (Bonis 2018; Canalejo Castrillero 2010)
Immunocompromised patients: Oral: 400 mg 5 times daily for 14 to 21 days (Bonis

2018)
Patients with severe odynophagia or dysphagia: IV: 5 mg/kg/dose every 8 hours;

patients who rapidly improve can be switched to an oral antiviral to complete a total
of 7 to 14 days of therapy (Bonis 2018; Canalejo Castrillero 2010).
Genital:
Immunocompetent patients:
Treatment, initial episode:
Oral: 400 mg 3 times daily or 200 mg 5 times daily for 7 to 10 days; extend
duration if lesions have not healed completely after 10 days (CDC
[Workowski 2015]).
IV (for severe disease): 5 to 10 mg/kg/dose every 8 hours for 2 to 7 days,

followed by oral acyclovir (or similar antiviral) to complete ≥10 days of
therapy total (CDC [Workowski 2015])
Treatment, recurrent episode: Oral: 400 mg 3 times daily for 5 days or 800 mg
twice daily for 5 days or 800 mg 3 times daily for 2 days. Note: Treatment is
most effective when initiated during the prodrome or within 1 day of lesion onset
(CDC [Workowski 2015]).
Suppressive therapy (eg, for severe and/or frequent recurrences): Oral: 400 mg
twice daily. Note: Reassess need periodically (eg, annually) (CDC [Workowski
2015]).
Immunocompromised patients (including HIV-infected):

Treatment, initial or recurrent episode:
Oral: 400 mg 3 times daily for 5 to 10 days; extend treatment duration if

lesions have not healed completely after 10 days (CDC [Workowski 2015];
HHS [OI adult 2018]; Wilck 2013).
IV (for severe disease): 5 to 10 mg/kg/dose every 8 hours for 2 to 7 days,

followed by oral acyclovir (or similar antiviral) once lesions begin to regress
and continue for ≥10 days of therapy and until complete resolution (CDC
[Workowski 2015]; HHS [OI adult 2018]).
Suppressive therapy (eg, for severe and/or frequent recurrences): Oral: 400 to
800 mg 2 to 3 times daily. Note: Reassess need periodically (eg, annually)
(CDC [Workowski 2015]; HHS [OI adult 2018]).
Pregnant females:
Treatment, initial episode: Oral: 400 mg 3 times daily for 7 to 10 days; extend
treatment duration if lesion has not healed completely after 10 days (ACOG
2007).
Treatment, recurrent episode (symptomatic): Oral: 400 mg 3 times daily or 800

mg twice daily for 5 days (ACOG 2007). Note: Some experts reserve treatment
of recurrent episodes for patients with severe and/or frequent symptoms (Riley
2018).
Suppressive therapy, for patients with a genital HSV lesion anytime during
pregnancy: Oral: 400 mg 3 times daily, beginning at 36 weeks' gestation and
continued until the onset of labor (ACOG 2007; CDC [Workowski 2015]; Riley
2018). Note: Some experts offer suppressive therapy earlier than 36 weeks'
gestation for women who have a first-episode lesion during the third trimester
(Riley 2018).
Orolabial: Note: Initiate therapy at earliest symptom.
Immunocompetent and immunocompromised patients (including HIV-infected):
Treatment, initial or recurrent episode:
Oral: 400 mg 3 times daily for 5 to 10 days and until complete lesion
resolution in immunocompromised patients (HHS [OI adult 2018]; Klein
2018; Wilck 2013)
IV (for severe disease in immunocompromised patients): 5 mg/kg/dose

every 8 hours; switch to oral acyclovir (or similar antiviral) once lesions

begin to regress and continue until complete resolution (HHS [OI adult
2018]; Wilck 2013).
Suppressive therapy (eg, for severe and/or frequent recurrences): Oral: 400 mg
twice daily (HHS [OI adult 2018]; Rooney 1993). Note: Reassess need
periodically (eg, annually) (HHS [adult OI 2018]).
Herpes simplex virus, prevention in immunocompromised patients (off-label use):
Seropositive HCT recipients (allogeneic or autologous) or seropositive patients

undergoing leukemia induction chemotherapy:
IV: 250 mg/m2/dose every 12 hours (ASBMT/IDSA [Tomblyn 2009])
Oral: 400 to 800 mg twice daily (ASBMT/IDSA [Tomblyn 2009])
Note: Initiate with the chemotherapeutic or conditioning regimen and continue until
recovery of WBC count and resolution of mucositis; duration may be extended in
patients with frequent recurrences or graft-vs-host disease (ASBMT/IDSA [Tomblyn
2009]; ASCO/IDSA [Taplitz 2018]).
Solid organ transplant recipients (HSV-seropositive patients who do not require CMV
prophylaxis): Oral: 400 to 800 mg twice daily for ≥1 month (Wilck 2013); some experts
recommend continuing for 3 to 6 months after transplantation and during periods of
lymphodepletion associated with treatment of rejection (Fishman 2018).
Herpes zoster (shingles), treatment:
Immunocompetent patients: Oral: 800 mg 5 times daily for 7 days (Pott Junior 2018;
Shafran 2004). Initiate at earliest sign or symptom; treatment is most effective when
initiated ≤72 hours after rash onset, but may initiate treatment >72 hours after rash onset
if new lesions are continuing to appear (Cohen 1999).
Acute localized dermatomal: Oral: 800 mg 5 times daily for 7 to 10 days; consider
longer duration if lesions resolve slowly (HHS [OI adult 2018]; Pergam 2013).
Extensive cutaneous lesions or visceral involvement: IV: 10 to 15 mg/kg/dose every

8 hours (HHS [OI adult 2018]; Pergam 2013). When formation of new lesions has
ceased and signs/symptoms of visceral infection are improving, switch to an oral
antiviral to complete a total of 10 to 14 days of therapy (HHS [OI adult 2018]).
Herpes zoster ophthalmicus (off-label use): Immunocompromised patients or patients who

require hospitalization for sight-threatening disease: IV: 10 mg/kg/dose every 8 hours for 7
days (Albrecht 2018a)
Varicella (chickenpox), treatment: Ideally initiate therapy within 24 hours of symptom onset,
but may start later if the patient still has active lesions:
Immunocompetent patients with uncomplicated infection: Oral: 800 mg 5 times daily for
≥5 to 7 days and until all lesions have crusted (Albrecht 2018b; Arvin 1996; Wallace
1992)
Severe or complicated infection: IV: 10 mg/kg/dose every 8 hours for 7 to 10 days

(HHS [OI adult 2018]; Pergam 2013); some experts recommend up to 15
mg/kg/dose every 8 hours (HHS [OI adult 2018]). May switch to oral antiviral after
defervescence if no evidence of visceral involvement; continue until all lesions have
crusted (HHS [OI adult 2018]; Pergam 2013).
Uncomplicated infection: Oral: 800 mg 5 times daily for 5 to 7 days (HHS [OI adult
2018]); some experts recommend a minimum duration of 7 days, extending the
course until all lesions have crusted (Albrecht 2018b; Pergam 2013).
Varicella zoster virus (VZV), acute retinal necrosis (off-label use): IV: 10 to 15
mg/kg/dose every 8 hours for 10 to 14 days, followed by ~6 weeks of valacyclovir (Albrecht
2018a; HHS [OI adult 2018]); in HIV-infected patients, intravitreal ganciclovir should be added
(HHS [OI adult 2018]).
Varicella zoster virus, encephalitis (off-label use): IV: 10 to 15 mg/kg/dose every 8 hours
for 10 to 14 days (IDSA [Tunkel 2008])
Varicella zoster virus, prevention in immunocompromised patients (off-label use):
Seropositive HCT recipients (allogeneic and autologous): Oral: 800 mg twice daily
(ASBMT/IDSA [Tomblyn 2009]; Boeckh 2006). Note: Initiate with the chemotherapeutic
or conditioning regimen and continue for 1 year; may extend duration in patients requiring
ongoing immunosuppression (some experts continue prophylaxis in these patients until 6
months after discontinuation of all systemic immunosuppression) (ASBMT/IDSA
[Tomblyn 2009]).
Solid organ transplant recipients (VZV-seropositive patients who do not require CMV
prophylaxis): Oral: 200 mg 3 to 5 times daily for 3 to 6 months after transplantation and
during periods of lymphodepletion associated with treatment of rejection (Fishman 2018;
Pergam 2013)
Dosing: Renal Impairment: Adult

Note: Monitor closely for neurotoxicity (Chowdhury 2016)

Note: The manufacturer's labeling dosing adjustments are reported as mL/minute/1.73 m2

based on data using CrCl adjusted for BSA (Blum 1982; de Miranda 1983).
Oral:
CrCl >25 mL/minute/1.73 m2: No dosage adjustment necessary.
CrCl 10 to 25 mL/minute/1.73 m2: If the usual recommended dose is 800 mg 5 times

daily: Administer 800 mg every 8 hours
CrCl <10 mL/minute/1.73 m2:
If the usual recommended dose is 200 mg 5 times daily or 400 mg every 12 hours:
Administer 200 mg every 12 hours
If the usual recommended dose is 800 mg 5 times daily: Administer 200 mg every 12
hours (IDSA [Gupta 2005])
Intermittent hemodialysis (IHD): Dialyzable (60% reduction following a 6-hour session):
Note: Dosing dependent on the assumption of 3-times-weekly, complete IHD

sessions. Administer after hemodialysis on dialysis days.
If the usual recommended dose is 200 mg 5 times daily or 400 mg every 12 hours:
Administer 200 mg every 12 hours
If the usual recommended dose is 800 mg 5 times daily: Administer a loading dose
of 400 mg and a maintenance dose of 200 mg twice daily plus a single 400 mg dose
after each dialysis (Almond 1995). Note: Dose based on pharmacokinetic data and
computer modeling.
Continuous ambulatory peritoneal dialysis (CAPD): 600 to 800 mg daily (Stathoulopoulou

1996)
IV:
If the usual recommended dose is 10 mg/kg/dose every 8 hours:
CrCl 25 to 50 mL/minute/1.73 m2: 10 mg/kg/dose every 12 hours
CrCl 10 to <25 mL/minute/1.73 m2: 10 mg/kg/dose every 24 hours
CrCl <10 mL/minute/1.73 m2: 5 mg/kg/dose every 24 hours
If the usual recommended dose is 5 mg/kg/dose every 8 hours:

CrCl 25 to 50 mL/minute/1.73 m2: 5 mg/kg/dose every 12 hours
CrCl 10 to <25 mL/minute/1.73 m2: 5 mg/kg/dose every 24 hours
CrCl <10 mL/minute/1.73 m2: 2.5 mg/kg/dose every 24 hours
Intermittent hemodialysis (IHD): Dialyzable (60% reduction following a 6-hour session):

2.5 to 5 mg/kg/dose every 24 hours (Heintz 2009). Note: Use higher end of dosing range
for viral meningoencephalitis and varicella-zoster infections. Dosing dependent on the
assumption of 3-times-weekly, complete IHD sessions. Administer after hemodialysis on
dialysis days
Peritoneal dialysis (PD): 2.5 to 5 mg/kg/dose every 24 hours; no supplemental dose

needed (Aronoff 2007). Note: Use higher end of dosing range for viral
meningoencephalitis and varicella-zoster infections.
Continuous renal replacement therapy (CRRT) (Heintz 2009): Drug clearance is highly
dependent on the method of renal replacement, filter type, and flow rate. Appropriate
dosing requires close monitoring of pharmacologic response, signs of adverse reactions
due to drug accumulation, as well as drug concentrations in relation to target trough (if
appropriate). The following are general recommendations only (based on dialysate
flow/ultrafiltration rates of 1 to 2 L/hour and minimal residual renal function) and should
not supersede clinical judgment:
CVVH: 5 to 10 mg/kg/dose every 24 hours
CVVHD/CVVHDF: 5 to 10 mg/kg/dose every 12 to 24 hours
Note: The higher end of dosage range is recommended for viral

meningoencephalitis and varicella-zoster virus infections.
Dosing: Hepatic Impairment: Adult

Oral, IV: There are no dosage adjustments provided in the manufacturer's labeling; use caution in
patients with severe impairment.
Dosage Forms: US
Excipient information presented when available (limited, particularly for generics); consult specific
product labeling. [DSC] = Discontinued product
Capsule, Oral:
Zovirax: 200 mg [DSC] [contains fd&c blue #2 (indigotine), parabens]
Generic: 200 mg
Solution, Intravenous, as sodium [strength expressed as base]:
Generic: 50 mg/mL (20 mL)
Solution, Intravenous, as sodium [strength expressed as base, preservative free]:
Generic: 50 mg/mL (10 mL, 20 mL)
Solution Reconstituted, Intravenous, as sodium [strength expressed as base]:
Generic: 500 mg (1 ea [DSC])
Suspension, Oral:
Zovirax: 200 mg/5 mL (473 mL) [contains methylparaben, propylparaben; banana flavor]
Generic: 200 mg/5 mL (473 mL)
Tablet, Oral:
Zovirax: 400 mg [DSC]
Zovirax: 800 mg [DSC] [contains fd&c blue #2 (indigotine)]
Generic: 400 mg, 800 mg
Generic Equivalent Available: US

Yes
Dosage Forms: Canada

Excipient information presented when available (limited, particularly for generics); consult specific
product labeling. [DSC] = Discontinued product
Solution, Intravenous:
Generic: 25 mg/mL (20 mL)
Solution, Intravenous, as sodium [strength expressed as base]:
Generic: 50 mg/mL (10 mL, 20 mL)
Solution Reconstituted, Intravenous, as sodium [strength expressed as base]:
Generic: 500 mg ([DSC])
Suspension, Oral:
Zovirax: 200 mg/5 mL (125 mL) [contains methylparaben, propylparaben]
Tablet, Oral:
Generic: 200 mg, 400 mg, 800 mg
Administration: Pediatric
Oral: May administer with or without food; shake suspension well before use. Maintain
adequate hydration during therapy.
Parenteral: Administer by slow IV infusion over at least 1 hour; rapid infusion is associated
with nephrotoxicity due to crystalluria and renal tubular damage and should be avoided.
Maintain adequate hydration during therapy. Do not administer IV push, IM, or SubQ.
Acyclovir IV is an irritant (depending on concentration); avoid extravasation. If

extravasation occurs, stop infusion immediately and disconnect (leave cannula/needle in
place); gently aspirate extravasated solution (do NOT flush the line); remove
needle/cannula; elevate extremity. Apply dry warm compresses. Intradermal
hyaluronidase may be considered for refractory cases (Reynolds 2014).
Administration: Adult
Oral: Administer with or without food.
IV: Avoid rapid infusion; infuse over 1 hour to prevent renal damage; maintain adequate
hydration of patient; check for phlebitis and rotate infusion sites. Do not administer IM or
SubQ. Acyclovir IV is an irritant (depending on concentration); avoid extravasation.
Storage/Stability
Capsule, oral suspension, tablet: Store at controlled room temperature of 15°C to 25°C (59°F
to 77°F); protect capsule and tablet from moisture.
Powder for injection: Store undiluted vials at 15°C to 25°C (59°F to 77°F). Following
reconstitution (final concentration 50 mg/mL), solution is stable for 12 hours at room
temperature.
Solution for injection: Store solution at 20°C to 25°C (68°F to 77°F).
Do not refrigerate reconstituted solutions or solutions diluted for infusion as they may
precipitate. Once diluted for infusion with NS or D5W, use within 24 hours.
Use
Parenteral: Treatment of initial and prophylaxis of recurrent mucosal and cutaneous herpes
simplex (HSV 1 and HSV 2) infections in immunocompromised patients (FDA approved in all
ages); treatment of severe initial episodes of herpes genitalis in immunocompetent patients
(FDA approved in ages ≥12 years and adults); treatment of herpes simplex encephalitis,

including neonatal herpes simplex virus (FDA approved in all ages); treatment of herpes
zoster (shingles) infections in immunocompromised patients (FDA approved in all ages)
Oral: Treatment of varicella (chickenpox) in immunocompetent patients (FDA approved in

ages ≥2 years and adults); treatment of initial episodes and prophylaxis of recurrent herpes
simplex (HSV 2, genital herpes) and acute treatment of herpes zoster (shingles) (FDA
approved in adults)
Has also been used for treatment of varicella-zoster infections in healthy, nonpregnant
persons >13 years of age, children >12 months of age who have a chronic skin or lung
disorder or are receiving long-term aspirin therapy, and immunocompromised patients; oral
therapy has also been used for suppression following parenteral treatment of neonatal HSV
infection
Medication Safety Issues

Sound-alike/look-alike issues:
Acyclovir may be confused with famciclovir, ganciclovir, Retrovir, valacyclovir,

valganciclovir
Zovirax may be confused with Doribax, Valtrex, Zithromax, Zostrix, Zyloprim, Zyvox
Adverse Reactions
As reported with IV administration, unless otherwise noted.
Central nervous system: Headache (oral), malaise (oral)
Dermatologic: Pruritus, skin rash, urticaria
Gastrointestinal: Diarrhea (oral and IV), nausea (oral and IV), vomiting (oral and IV)
Hematologic & oncologic: Decrease in absolute neutrophil count (neonates), decreased

hemoglobin (neonates), thrombocytopenia (more common in neonates)
Hepatic: Increased serum bilirubin (neonates), increased serum transaminases
Local: Inflammation at injection site, injection site phlebitis
Renal: Increased blood urea nitrogen, increased serum creatinine
Rare but important or life-threatening (all routes): Abdominal pain, aggressive behavior,
agitation, alopecia, anaphylaxis, anemia, angioedema, anorexia, ataxia, coma, confusion,
delirium, disseminated intravascular coagulation, dizziness, drowsiness, dysarthria,
encephalopathy, erythema multiforme, fatigue, fever, gastrointestinal distress, hallucination,
hematuria, hemolysis, hepatitis, hyperbilirubinemia, hypersensitivity angiitis, hypotension,

impaired consciousness, increased liver enzymes, jaundice, leukocytosis, leukopenia,

lymphadenopathy, myalgia, neutropenia, neutrophilia, obtundation, pain, paresthesia,
peripheral edema, psychosis, renal failure syndrome, renal pain, seizure, skin photosensitivity,
Stevens-Johnson syndrome, thrombocythemia, toxic epidermal necrolysis, tremor, visual
disturbance
Contraindications
Hypersensitivity to acyclovir, valacyclovir, or any component of the formulation
Warnings/Precautions
Concerns related to adverse effects:
• CNS effects: Neurotoxicity (eg, tremor/myoclonus, confusion, agitation, lethargy,

hallucination, impaired consciousness) has been reported; risk may be increased with
higher doses and in patients with renal failure. Monitor patients for signs/symptoms of
neurotoxicity; ensure appropriate dosage reductions in patients with renal impairment
(Chowdhury 2016).
• Extravasation: Acyclovir IV is an irritant (depending on concentration); avoid

extravasation.
• Renal effects: Renal failure (sometimes fatal) has been reported. Dehydration,
preexisting renal disease, and nephrotoxic drugs increase risk; ensure patient is
adequately hydrated during oral or IV therapy.
• Thrombotic microangiopathy: Has been reported in immunocompromised patients

receiving acyclovir.
Disease-related concerns:
• Renal impairment: Use with caution; dosage adjustment recommended. Neurotoxicity

may be more common in patients with renal impairment (Chowdhury 2016).
• Varicella: Appropriate use: For maximum benefit, treatment should begin within 24
hours of appearance of rash; oral route not recommended for routine use in otherwise
healthy children with varicella but may be effective in patients at increased risk of
moderate-to-severe infection (>12 years of age, chronic cutaneous or pulmonary
disorders, long-term salicylate therapy, corticosteroid therapy).
Concurrent drug therapy issues:
• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or

frequency adjustment, additional monitoring, and/or selection of alternative therapy.
Consult drug interactions database for more detailed information.
Dosage form specific issues:
• Injection: Use IV preparation with caution in patients with underlying neurologic

abnormalities, serious hepatic or electrolyte abnormalities, or substantial hypoxia.
Encephalopathic changes characterized by lethargy, obtundation, confusion,
hallucination, tremors, agitation, seizure, or coma have been observed in patients
receiving IV acyclovir.
Other warnings/precautions:
• Adequate hydration: Maintain adequate hydration during oral or IV therapy.
Warnings: Additional Pediatric Considerations

Acyclovir can cause intrarenal obstructive nephropathy, interstitial nephritis, and tubular necrosis
resulting in significant renal insufficiency. In one study, 35% (131/373 courses) in 371 pediatric
patients treated with IV acyclovir mostly for meningoencephalitis were observed to have renal
dysfunction. Renal dysfunction typically occurred within 48 hours of initiation and was reversible in
most cases after dosage reduction or discontinuation, although in some instances, return to
baseline was not observed. Analysis of the degree of dysfunction based on percent reduction of
estimated GFR (eGFR) showed that of the 373 acyclovir courses, 22% (81/373) had an eGFR
reduction of 25% to 49%, renal injury (defined as a 50% to 75% reduction in eGFR) in 9.7%
(36/373), and renal failure (eGFR reduction >75%) in 3.8% (14/373). Doses >500 mg/m2 were
significantly associated with all levels of nephrotoxicity and acyclovir doses >15 mg/kg were
significantly associated with a 25% to 49% reduction in eGFR. Statistically significant risk factors
for renal failure identified through univariate analysis were age >8 years, weight >20 kg, BMI >19
kg/m2, and concurrent ceftriaxone with or without gadolinium. Associations of other antibiotics and
contrast agents were not statistically significant. Monitor renal function during therapy, particularly
for high doses and in older pediatric patients (>8 years). Outside of the neonatal period, reduced
dosing or use of mg/m2 dosing in larger children may need to be considered; further studies are
necessary (Rao 2015).
Metabolism/Transport Effects
Inhibits CYP1A2 (weak)
Drug Interactions
(For additional information: Launch drug interactions program)
Cladribine: Agents that Undergo Intracellular Phosphorylation may diminish the therapeutic
effect of Cladribine. Risk X: Avoid combination
CloZAPine: CYP1A2 Inhibitors (Weak) may increase the serum concentration of CloZAPine.
Management: Drugs listed as exceptions to this monograph are discussed in further detail in
separate drug interaction monographs. Risk C: Monitor therapy
Foscarnet: May enhance the nephrotoxic effect of Acyclovir-Valacyclovir. Risk X: Avoid

combination
Mycophenolate: Acyclovir-Valacyclovir may increase the serum concentration of

Mycophenolate. Mycophenolate may increase the serum concentration of Acyclovir-
Valacyclovir. Risk C: Monitor therapy
Talimogene Laherparepvec: Antiherpetic Antivirals may diminish the therapeutic effect of

Talimogene Laherparepvec. Risk C: Monitor therapy
Tenofovir Products: Acyclovir-Valacyclovir may increase the serum concentration of Tenofovir

Products. Tenofovir Products may increase the serum concentration of Acyclovir-Valacyclovir.
Risk C: Monitor therapy
Theophylline Derivatives: CYP1A2 Inhibitors (Weak) may increase the serum concentration of
Theophylline Derivatives. Exceptions: Dyphylline. Risk C: Monitor therapy
TiZANidine: CYP1A2 Inhibitors (Weak) may increase the serum concentration of TiZANidine.
Management: Avoid these combinations when possible. If combined use is necessary, initiate
tizanidine at an adult dose of 2 mg and increase in 2 to 4 mg increments based on patient
response. Monitor for increased effects of tizanidine, including adverse reactions. Risk D:
Consider therapy modification
Varicella Virus Vaccine: Acyclovir-Valacyclovir may diminish the therapeutic effect of Varicella
Virus Vaccine. Management: When possible, avoid use of acyclovir or valacyclovir within the
24 hours prior to administration of the varicella vaccine, and avoid use of these antiviral
agents for 14 days after vaccination. Risk X: Avoid combination
Zidovudine: Acyclovir-Valacyclovir may enhance the CNS depressant effect of Zidovudine.

Risk C: Monitor therapy
Zoster Vaccine (Live/Attenuated): Acyclovir-Valacyclovir may diminish the therapeutic effect of

Zoster Vaccine (Live/Attenuated). Risk X: Avoid combination
Dietary Considerations
Some products may contain sodium.
Pregnancy Considerations
Acyclovir has been shown to cross the human placenta (Henderson 1992).
Results from a pregnancy registry, established in 1984 and closed in 1999, did not find an
increase in the number of birth defects with exposure to acyclovir when compared to those
expected in the general population. However, due to the small size of the registry and lack of long-
term data, the manufacturer recommends using during pregnancy with caution and only when
clearly needed. Acyclovir is recommended for the treatment of genital herpes in pregnant patients
(ACOG 2007; CDC [Workowski 2015]).
Monitoring Parameters
Urinalysis, BUN, serum creatinine, urine output; liver enzymes, CBC; monitor for neurotoxicity and
nephrotoxicity when using high dose therapy; neutrophil count at least twice weekly in neonates
receiving acyclovir 60 mg/kg/day IV
Mechanism of Action
Acyclovir is converted to acyclovir monophosphate by virus-specific thymidine kinase then further
converted to acyclovir triphosphate by other cellular enzymes. Acyclovir triphosphate inhibits DNA
synthesis and viral replication by competing with deoxyguanosine triphosphate for viral DNA
polymerase and being incorporated into viral DNA.
Pharmacodynamics and Pharmacokinetics (Adult data unless noted)
Absorption: Oral: Poorly absorbed; absorption improves with multiple small doses compared
to one large daily dose (de Miranda 1983)
Distribution: Widely (eg, brain, kidney, lungs, liver, spleen, muscle, uterus, vagina, CSF) (de
Miranda 1983; Laskin 1983); CSF acyclovir concentration is ~50% of plasma concentrations.
Vdss (Blum 1982; Laskin 1983; Spector 1981):
Neonates to 3 months of age: 28.8 L/1.73 m2
Children 1 to 2 years: 31.6 L/1.73 m2
Children 2 to 7 years: 42 L/1.73 m2
Adults: 0.8 L/kg (63.6 L)
Protein binding: 9% to 33%
Metabolism: Converted by viral enzymes to acyclovir monophosphate, and further converted

to diphosphate then triphosphate (active form) by cellular enzymes
Bioavailability: Oral: 10% to 20% with normal renal function (bioavailability decreases with
increased dose)
Half-life elimination: Terminal: Neonates and Infants ≤3 months: 3.8 ± 1.19 hours; Infants >3
months to Children ≤12 years: 2.36 ± 0.97 hours; Adults: ~2.5 hours (with normal renal
function); 20 hours (ESRD) (Gorlitsky 2017); Hemodialysis: ~5 hours
Excretion: Urine (62% to 91% as unchanged drug and metabolite)

Pharmacodynamics and Pharmacokinetics: Additional Considerations
Renal function impairment: Total body clearance and half-life are dependent on renal function.
Additional Information
Sodium content of 1 g: 5.1 mEq
Pricing: US
Capsules (Acyclovir Oral)
200 mg (per each): $0.13 - $2.92
Solution (Acyclovir Sodium Intravenous)
50 mg/mL (per mL): $0.52 - $2.26
Suspension (Acyclovir Oral)
200 mg/5 mL (per mL): $0.90 - $0.94
Suspension (Zovirax Oral)
200 mg/5 mL (per mL): $1.24
Tablets (Acyclovir Oral)
400 mg (per each): $0.21 - $2.17
800 mg (per each): $0.36 - $4.22
Tablets (Zovirax Oral)
400 mg (per each): $11.01
800 mg (per each): $21.41
Disclaimer: A representative AWP (Average Wholesale Price) price or price range is provided as
reference price only. A range is provided when more than one manufacturer's AWP price is
available and uses the low and high price reported by the manufacturers to determine the range.
The pricing data should be used for benchmarking purposes only, and as such should not be used
alone to set or adjudicate any prices for reimbursement or purchasing functions or considered to
be an exact price for a single product and/or manufacturer. Medi-Span expressly disclaims all
warranties of any kind or nature, whether express or implied, and assumes no liability with respect
to accuracy of price or price range data published in its solutions. In no event shall Medi-Span be
liable for special, indirect, incidental, or consequential damages arising from use of price or price
range data. Pricing data is updated monthly.

Brand Names: International

Acic (AE, BH, EE, KW, LV, QA); Aciclodan (DK); Aciclor (VE); Aciclosina (PT); Acicvir (NZ);
Aciherpin (PH); Acirax (LK, VN); Acivir (BD, EG, ET, LV); Acivir Eye (IN); Acivirex (GT, HN, NI,
SV); Aclovir (FI, TH, TW); Acovir (ZW); ACS (KR); Activir (FR); Acyclo-V (AU, BH); Acyclovenir
(IL); Acylene (MY); Acyrax (FI); Acyvir (EC, IT, VN); Aisike (CN); Aisile (CN); Alovir (ZW); Alvoles
(TH); Antix (NO); Avir (VE); Avorax (HK); Azost (PH); Bangna (CN); Bearax (SG); Biraxin (PH);
Ciclevir (VN); Cicloferon (CR, DO, GT, HN, MX, NI, PA, SV); Cicloviral (CO); Ciclox (PH); Clinovir
(ID, TH); Clopes (ID); Clovika (ID); Clovir (KR, PH, PY, QA); Clovirex (LK); Covelay (PH); Cusiviral
(MY, QA, SG); Cyclivex (ZA); Cycloherp (HK); Cyclostad (PH); Cyclovax (TR, ZW); Cyclovex (LB);
Cyclovir (BF, BJ, CI, ET, GH, GM, GN, KE, LR, MA, ML, MR, MU, MW, NE, NG, SC, SD, SL, SN,
TN, TZ, UG, ZM, ZW); Cyllanvir (PH); Deherp (TH, TW); Dravyr (MY, SG); Duvimex (AE, BH, CY,
EG, IQ, IR, JO, KW, LB, LY, OM, QA, SA, SY, YE); Ecuvir (EC); Entir (SG, TH); Erlvirax (SG);
Euroclovir (HK); Eurovir (PY); Expit (UY); Gantai (CN); Geavir (DK, SE); Helvevir (CH); Herax (ID);
Herpavir (JO); Herperax (ZW); Herpesin (CZ, SK); Herpevex (MY); Herpevir (FR); Herpex (BH,
ET, IN, PH, ZW); Herpirax (NL); Herpizyg (TH); Heviran (PL); Isavir (CR, DO, GT, HN, NI, PA, SV);
Lermex (TH); Licovir (ID); Lisovyr (AR, CL); Lovir (AE, AU, EG, KW, NZ, PH, QA); Lovire (ZA);
Marvir (TH); Matrovir (ID); Medovir (AE, BF, BG, BH, BJ, CI, CY, EG, ET, GH, GM, GN, IQ, IR, JO,
KE, KW, LB, LR, LY, MA, ML, MR, MU, MW, MY, NE, NG, OM, QA, SA, SC, SD, SG, SL, SN, SY,
TN, TW, TZ, UG, YE, ZM, ZW); Mibeviru (VN); Molavir (ID); Norum (TH); Noviral (QA); Ozvir (AU);
Poviral (AR); Qualiclovir (HK); Ranvir (TH); Reclovax (TH); Remex (FR); Skirax (TW); Supraviran
(JO, LB); Vacrax (MY); Vermis (TH); Vialesel (ET); Vilerm (SG); Viralex-DS (PH); Viramed (ZW);
Viratak (ZW); Viratop (BE); Virax (KR); Virest (HK, SG); Virex (CO); Virherpes (ES); Virless (LK,
MY, SG, TW); Viroclear (HK); Virogon (TH); Virolex (HU, RO); Virolox (HR); Viromed (TH); Virpes
(AE, JO); Virucid (MT, TR, VN); Virustat (JO); Virzin (DE); Vivir (KR); Wariviron (LB, QA); Xovir
(BD); Zevin (TH); Ziverone (MX); Zodiac (KR); Zoral (HK, MY, SG); Zorax (MY, SG); Zorexin (MY);
Zoter (ID); Zovir (DK, IS); Zovirax (AE, AR, AT, AU, BB, BD, BE, BF, BG, BH, BJ, BM, BO, BR, BS,
CH, CI, CU, CY, CZ, EC, EE, EG, ET, FI, FR, GB, GH, GM, GN, GR, GY, HK, HU, ID, IE, IL, IN,
IQ, IR, IT, JM, JO, JP, KE, KR, KW, LB, LR, LU, LV, LY, MA, ML, MR, MT, MU, MW, MY, NE, NG,
NL, NO, NZ, OM, PE, PH, PK, PL, PR, PT, PY, QA, RU, SA, SC, SD, SE, SK, SL, SN, SY, TN, TR,
TT, TW, TZ, UA, UG, UY, YE, ZA, ZM, ZW); Zoylex (PE); Zyvir (KE)
For country abbreviations used in Lexicomp (show table)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES

1. ACOG Committee on Practice Bulletins. ACOG Practice Bulletin. Clinical management guidelines for
obstetrician-gynecologists. No. 82 June 2007. Management of herpes in pregnancy. Obstet Gynecol.
2007;109(6):1489-1498. [PubMed 17569194]
2. Acyclovir capsule, tablet [prescribing information]. Fort Lee, NJ: DAVA Pharmaceuticals, Inc; April 2014.
3. Acyclovir injection, powder, lyophilized, for solution [prescribing information]. Schaumberg, IL: AAP
Pharmaceuticals, LLC: January 2008.
4. Acyclovir injection, solution [prescribing information]. Dayton, NJ: AuroMedics Pharma LLC; January 2014.
5. Acyclovir oral [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; 2014.
6. Adour KK, Ruboyianes JM, Von Doersten PG, et al. Bell's palsy treatment with acyclovir and prednisone
compared with prednisone alone: a double-blind, randomized, controlled trial. Ann Otol Rhinol Laryngol.
1996;105(5):371-378. doi: 10.1177/000348949610500508. [PubMed 8651631]
7. Albrecht MA. Treatment of herpes zoster in the immunocompetent host. Post TW, ed. UpToDate. Waltham,
MA: UpToDate Inc. http://www.uptodate.com. Accessed October 18, 2018a.
8. Albrecht MA. Treatment of varicella (chickenpox) infection. Post TW, ed. UpToDate. Waltham, MA: UpToDate
Inc. http://www.uptodate.com. Accessed May 24, 2018b.
9. Almond MK, Fan S, Dhillon S, Pollock AM, Raftery MJ. Avoiding acyclovir neurotoxicity in patients with
chronic renal failure undergoing haemodialysis. Nephron. 1995;69(4):428-432. doi: 10.1159/000188514.
[PubMed 7777108]
10. American Academy of Pediatrics (AAP). In: Kimberlin DW, Brady MT, Jackson MA, Long SA, eds; Red Book:
2015 Report of the Committee on Infectious Diseases. 30th ed. Elk Grove Village, IL: American Academy of
Pediatrics; 2015.
11. American Academy of Pediatrics Committee on Infectious Diseases, “The Use of Oral Acyclovir in Otherwise
Healthy Children With Varicella,” Pediatrics, 1993, 91(3):674-6. [PubMed 8382784]
12. Amir J, Harel L, Smetana Z, Varsano I. Treatment of herpes simplex gingivostomatitis with aciclovir in
children: a randomised double blind placebo controlled study. BMJ. 1997;314(7097):1800-1803. [PubMed
9224082]
13. Anderson PO, Sauberan JB. Modeling drug passage into human milk. Clin Pharmacol Ther. 2016;100(1):42-
52. [PubMed 27060684]
14. Aronoff GR, Bennett WM, Berns JS, et al. Drug Prescribing in Renal Failure: Dosing Guidelines for Adults
and Children. 5th ed. Philadelphia, PA: American College of Physicians; 2007.
15. Arvin AM. Varicella-zoster virus. Clin Microbiol Rev. 1996;9(3):361-381. [PubMed 8809466]
16. Balfour HH Jr. Antiviral drugs. N Engl J Med. 1999;340(16):1255-1268. doi:

10.1056/NEJM199904223401608. [PubMed 10210711]

17. Baugh RF, Basura GJ, Ishii LE, et al. Clinical practice guideline: Bell's palsy. Otolaryngol Head Neck Surg.
2013;149(3)(suppl):S1-S27. doi: 10.1177/0194599813505967. [PubMed 24189771]
18. Bergmann OJ, Ellermann-Eriksen S, Mogensen SC, Ellegaard J. Acyclovir given as prophylaxis against oral
ulcers in acute myeloid leukaemia: randomised, double blind, placebo controlled trial. BMJ.
1995;310(6988):1169-1172. [PubMed 7767151]
19. Blum MR, Liao SH, de Miranda P. Overview of acyclovir pharmacokinetic disposition in adults and children.
Am J Med. 1982;73(1A):186-192. [PubMed 7048911]
20. Boeckh M, Kim HW, Flowers ME, Meyers JD, Bowden RA. Long-term acyclovir for prevention of varicella
zoster virus disease after allogeneic hematopoietic cell transplantation--a randomized double-blind placebo-
controlled study. Blood. 2006;107(5):1800-1805. doi: 10.1182/blood-2005-09-3624. [PubMed 16282339]
21. Boeckh M, Ljungman P. How we treat cytomegalovirus in hematopoietic cell transplant recipients. Blood.
2009;113(23):5711-5719. doi: 10.1182/blood-2008-10-143560. [PubMed 19299333]
22. Bonis PA, Kotton CN. Herpes simplex virus infection of the esophagus. Post TW, ed. UpToDate. Waltham,
MA: UpToDate Inc. http://www.uptodate.com. Accessed September 28, 2018.
23. Bork K, Benes P. Concentration and kinetic studies of intravenous acyclovir in serum and breast milk of a
patient with eczema herpeticum. J Am Acad Dermatol. 1995;32(6):1053-1055. [PubMed 7751454]
24. Bradley JS, Nelson JD, Kimberlin DK, et al, eds. Nelson's Pocket Book of Pediatric Antimicrobial Therapy.
19th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012.
25. Bradley JS, Nelson JD, Kimberlin DK, et al, eds. Nelson's Pocket Book of Pediatric Antimicrobial Therapy.
21st ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2015.
26. Canalejo Castrillero E, García Durán F, Cabello N, García Martínez J. Herpes esophagitis in healthy adults
and adolescents: report of 3 cases and review of the literature. Medicine (Baltimore). 2010;89(4):204-210.
doi: 10.1097/MD.0b013e3181e949ed. [PubMed 20616659]
27. Centers for Disease Control and Prevention (CDC), "Sexually Transmitted Diseases Treatment Guidelines,
2010," MMWR Recomm Rep, 2010, 59(RR-12):1-110. [PubMed 21160459]
28. Cernik C, Gallina K, Brodell RT. The treatment of herpes simplex infections: an evidence-based review. Arch
Intern Med. 2008;168(11):1137-1144. doi: 10.1001/archinte.168.11.1137. [PubMed 18541820]
29. Chamizo FJ, Gilarranz R, Hernández M, Ramos D, Pena MJ. Central nervous system infections caused by
varicella-zoster virus. J Neurovirol. 2016;22(4):529-532. doi: 10.1007/s13365-016-0422-y. [PubMed
26769041]
30. Chowdhury MA, Derar N, Hasan S, Hinch B, Ratnam S, Assaly R. Acyclovir-induced neurotoxicity: a case
report and review of literature. Am J Ther. 2016;23(3):e941-e943. doi: 10.1097/MJT.0000000000000093.
[PubMed 24942005]

31. Cohen JI, Brunell PA, Straus SE, Krause PR. Recent advances in varicella-zoster virus infection. Ann Intern
Med. 1999;130(11):922-932. [PubMed 10375341]
32. de Almeida JR, Guyatt GH, Sud S, et al; Bell Palsy Working Group, Canadian Society of Otolaryngology -
Head and Neck Surgery and Canadian Neurological Sciences Federation. Management of Bell palsy: clinical
practice guideline. CMAJ. 2014;186(12):917-922. doi: 10.1503/cmaj.131801. [PubMed 24934895]
33. de Miranda P, Blum MR. Pharmacokinetics of acyclovir after intravenous and oral administration. J
Antimicrob Chemother. 1983;12(suppl B):29-37. [PubMed 6355048]
34. DHHS Panel on Opportunistic Infections (OI) in HIV-Infected Adults and Adolescents. Guidelines for
prevention and treatment of opportunistic infections in HIV-infected adults and adolescents:
recommendations from the Centers for Disease Control and Prevention (CDC), the National Institutes of
Health (NIH), and the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America
(IDSA). April 8, 2015. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf
35. DHHS Panel on Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Guidelines for the
Prevention and Treatment of Opportunistic Infections in HIV-Exposed and HIV-Infected Children. Department
of Health and Human Services. November 2013.
http://aidsinfo.nih.gov/contentfiles/lvguidelines/oi_guidelines_pediatrics.pdf.
36. Englund JA, Fletcher CV, and Balfour HH Jr, “Acyclovir Therapy in Neonates,” J Pediatr, 1991, 119(1 Pt
1):129-35. [PubMed 2066845 ]
37. Fishman JA, Alexander BD. Prophylaxis of infections in solid organ transplantation. Post TW, ed. UpToDate.
Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 26, 2018.
38. Freifeld AG, Bow EJ, Sepkowitz KA, et al; Infectious Diseases Society of America. Clinical practice guideline
for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious
Diseases Society of America. Clin Infect Dis. 2011;52(4):427-431. [PubMed 21205990]
39. Gartner LM, Morton J, Lawrence RA, et al; American Academy of Pediatrics Section on Breastfeeding.
Breastfeeding and the use of human milk. Pediatrics. 2005;115(2):496-506. doi: 10.1542/peds.2004-2491
[PubMed 15687461]
40. Gorlitsky BR, Herion JT. Sticking to the script: A curious case of confusion in an ESRD patient. Hemodial Int.
2017;21(3):E58-E62. doi: 10.1111/hdi.12534. [PubMed 28067468]
41. Gronseth GS, Paduga R; American Academy of Neurology. Evidence-based guideline update: steroids and
antivirals for Bell palsy: report of the Guideline Development Subcommittee of the American Academy of
Neurology. Neurology. 2012;79(22):2209-2213. doi: 10.1212/WNL.0b013e318275978c. [PubMed 23136264]
42. Gupta SK, Eustace JA, Winston JA, et al. Guidelines for the management of chronic kidney disease in HIV-
infected patients: recommendations of the HIV Medicine Association of the Infectious Diseases Society of
America. Clin Infect Dis. 2005;40(11):1559-1585. doi: 10.1086/430257 [PubMed 15889353]
43. Heintz BH, Matzke GR, Dager WE. Antimicrobial dosing concepts and recommendations for critically ill adult
patients receiving continuous renal replacement therapy or intermittent hemodialysis. Pharmacotherapy.

2009;29(5):562-577. doi: 10.1592/phco.29.5.562. [PubMed 19397464]
44. Henderson GI, Hu ZQ, Johnson RF, Perez AB, Yang Y, Schenker S. Acyclovir transport by the human
placenta [published correction appears in: J Lab Clin Med 1993;121(5):705.]. J Lab Clin Med.
1992;120(6):885-892. [PubMed 1453110]
45. Hyland PL, Coulter WA, Abu-Ruman I, et al. Asymptomatic shedding of HSV-1 in patients undergoing oral
surgical procedures and attending for noninvasive treatment. Oral Dis. 2007;13(4):414-418. [PubMed
17577329]
46. Ito S. Drug therapy for breast-feeding women. N Engl J Med. 2000;343(2):118-126. doi:
10.1056/NEJM200007133430208 [PubMed 10891521]
47. Kimberlin DW, Whitley RJ, Wan W, et al; National Institute of Allergy and Infectious Diseases Collaborative
Antiviral Study Group. Oral acyclovir suppression and neurodevelopment after neonatal herpes. N Engl J
Med. 2011;365(14):1284-1292. doi: 10.1056/NEJMoa1003509. [PubMed 21991950]
48. Kimberlin DW, Lin CY, Jacobs RF, et al, “Safety and Efficacy of High-Dose Intravenous Acyclovir in the
Management of Neonatal Herpes Simplex Virus Infections,” Pediatrics, 2001, 108(2):230-8. [PubMed
11483782]
49. Kimberlin DW, Baley J; Committee on Infectious Diseases; Committee on Fetus and Newborn. Guidance on
management of asymptomatic neonates born to women with active genital herpes lesions. Pediatrics.
2013;131(2):e635-e646. doi: 10.1542/peds.2012-3216. [PubMed 23359576]
50. Klein RS. Treatment of herpes simplex virus type 1 infection in immunocompetent patients. Post TW, ed.
UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 26, 2018.
51. Laskin OL. Clinical pharmacokinetics of acyclovir. Clin Pharmacokinet. 1983;8(3):187-201. [PubMed
6342900]
52. Lau RJ, Emery MG, Galinsky RE. Unexpected accumulation of acyclovir in breast milk with estimation of
infant exposure. Obstet Gynecol. 1987;69(3, pt 2):468-471. [PubMed 3808527]
53. Leflore S, Anderson PL, Fletcher CV. A risk-benefit evaluation of aciclovir for the treatment and prophylaxis
of herpes simplex virus infections. Drug Saf. 2000;23(2):131-142. [PubMed 10945375]
54. Ljungman P, de La Camara R, Milpied N, et al; Valacyclovir International Bone Marrow Transplant Study
Group. Randomized study of valacyclovir as prophylaxis against cytomegalovirus reactivation in recipients of
allogeneic bone marrow transplants. Blood. 2002;99(8):3050-3056. [PubMed 11929799]
55. MacPhail L, Greenspan D. Herpetic gingivostomatitis in a 70-year-old man. Oral Surg Oral Med Oral Pathol
Oral Radiol Endod. 1995;79(1):50-52. [PubMed 7614161]
56. Ogilvie MM, "Antiviral Prophylaxis and Treatment in Chickenpox. A Review Prepared for the UK Advisory
Group on Chickenpox on Behalf of the British Society for the Study of Infection," J Infect, 1998, 36(Suppl
10):31-8. [PubMed 9514106]

57. Pergam SA, Limaye AP; AST Infectious Diseases Community of Practice. Varicella zoster virus in solid organ
transplantation. Am J Transplant. 2013;13(suppl 4):138-146. doi: 10.1111/ajt.12107. [PubMed 23465007]
58. Pott Junior H, de Oliveira MFB, Gambero S, Amazonas RB. Randomized clinical trial of famciclovir or
acyclovir for the treatment of herpes zoster in adults. Int J Infect Dis. 2018;72:11-15. doi:
10.1016/j.ijid.2018.04.4324. [PubMed 29746903]
59. Raborn GW, Martel AY, Grace MG, McGaw WT. Oral acyclovir in prevention of herpes labialis. A randomized,
double-blind, multi-centered clinical trial. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998;85(1):55-
59. [PubMed 9474615]
60. Rahimi H, Mara T, Costella J, Speechley M, Bohay R. Effectiveness of antiviral agents for the prevention of
recurrent herpes labialis: a systematic review and meta-analysis. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2012;113(5):618-627. doi: 10.1016/j.oooo.2011.10.010. [PubMed 22668620]
61. Rao S, Abzug MJ, Carosone-Link P, et al. Intravenous acyclovir and renal dysfunction in children: a matched
case control study. J Pediatr. 2016;166(6):1462-14628.e1-4. doi: 10.1016/j.jpeds.2015.01.023. [PubMed
25708691]
62. Red Book: 2009 Report of the Committee on Infectious Diseases, 28th ed, Pickering LK, ed, Elk Grove
Village, IL: American Academy of Pediatrics, 2009.
63. Reynolds PM, MacLaren R, Mueller SW, Fish DN, Kiser TH. Management of extravasation injuries: a
focused evaluation of noncytotoxic medications. Pharmacotherapy. 2014;34(6):617-632. [PubMed 24420913]
64. Riley LE, Wald A. Genital herpes simplex virus infection and pregnancy. Post TW, ed. UpToDate. Waltham,
MA: UpToDate Inc. http://www.uptodate.com. Accessed September 27, 2018.
65. Ronthal M. Bell’s palsy: treatment and prognosis. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.
http://www.uptodate.com. Accessed September 26, 2018.
66. Rooney JF, Straus SE, Mannix ML, et al. Oral acyclovir to suppress frequently recurrent herpes labialis. a
double-blind, placebo-controlled trial. Ann Intern Med. 1993;118(4):268-272. [PubMed 8380540]
67. Sauerbrei A and Wutzler P, "Herpes Simplex and Varicella-Zoster Virus Infections During Pregnancy: Current
Concepts of Prevention, Diagnosis and Therapy. Part 2: Varicella-Zoster Virus Infections," Med Microbiol
Immunol, 2007, 196(2):95-102. [PubMed 17180380]
68. Shafran SD, Tyring SK, Ashton R, et al. Once, twice, or three times daily famciclovir compared with aciclovir
for the oral treatment of herpes zoster in immunocompetent adults: a randomized, multicenter, double-blind
clinical trial. J Clin Virol. 2004;29(4):248-253. [PubMed 15018852]
69. Smith CK and Arvin AM, "Varicella in the Fetus and Newborn," Semin Fetal Neonatal Med, 2009, 14(4):209-
17. [PubMed 19097954]
70. Spector SA, Connor JD, Hintz M, Quinn RP, Blum MR, Keeney RE. Single-dose pharmacokinetics of
acyclovir. Antimicrob Agents Chemother. 1981;19(4):608-612. [PubMed 7247383]

71. Spruance SL, Hamill ML, Hoge WS, Davis LG, Mills J. Acyclovir prevents reactivation of herpes simplex
labialis in skiers. JAMA. 1988;260(11):1597-1599. [PubMed 3411740]
72. Spruance SL, Stewart JC, Rowe NH, McKeough MB, Wenerstrom G, Freeman DJ. Treatment of recurrent
herpes simplex labialis with oral acyclovir. J Infect Dis. 1990;161(2):185-190. [PubMed 2153735]
73. Stathoulopoulou F, Almond MK, Dhillon S, Raftery MJ. Clinical pharmacokinetics of oral acyclovir in patients
on continuous ambulatory peritoneal dialysis. Nephron. 1996;74(2):337-341. doi: 10.1159/000189332.
[PubMed 8893152]
74. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin
and soft tissue infections: 2014 update by the infectious diseases society of America. Clin Infect Dis.
2014;59(2):147-159. doi: 10.1093/cid/ciu296. [PubMed 24947530]
75. Taddio A, Klein J, Koren G. Acyclovir excretion in human breast milk. Ann Pharmacother. 1994;28(5):585-
587. doi: 10.1177/106002809402800506. [PubMed 8068994]
76. Taplitz RA, Kennedy EB, Bow EJ, et al. Antimicrobial prophylaxis for adult patients with cancer-related
immunosuppression: ASCO and IDSA clinical practice guideline update [published online ahead of print
September 4, 2018]. J Clin Oncol. doi: 10.1200/JCO.18.00374. [PubMed 30179565]
77. Tiffany KF, Benjamin DK Jr, Palasanthiran P, et al. Improved neurodevelopmental outcomes following long-
term high-dose oral acyclovir therapy in infants with central nervous system and disseminated herpes
simplex disease. J Perinatol. 2005;25(3):156-161.doi: 10.1038/sj.jp.7211247. [PubMed 15605069]
78. Tomblyn M, Chiller T, Einsele H, et al; Center for International Blood and Marrow Research; National Marrow
Donor Program; European Blood and Marrow Transplant Group; et al. Guidelines for preventing infectious
complications among hematopoietic cell transplantation recipients: a global perspective [published correction
appears in Biol Blood Marrow Transplant. 2010;16(2):294]. Biol Blood Marrow Transplant. 2009;15(10):1143-
1238. doi: 10.1016/j.bbmt.2009.06.019. [PubMed 19747629]
79. Trotman RL, Williamson JC, Shoemaker DM, et al, "Antibiotic Dosing in Critically Ill Adult Patients Receiving
Continuous Renal Replacement Therapy," Clin Infect Dis, 2005, 41:1159-66. [PubMed 16163635]
80. Tunkel AR, Glaser CA, Bloch KC, et al; Infectious Diseases Society of America. The management of
encephalitis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis.
2008;47(3):303-327. doi: 10.1086/589747. [PubMed 18582201]
81. Tunkel AR. Aseptic meningitis in adults. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.
http://www.uptodate.com. Accessed December 17, 2018.
82. Turner RB, Cumpston A, Sweet M, et al. Prospective, controlled study of acyclovir pharmacokinetics in obese
patients. Antimicrob Agents Chemother. 2016;60(3):1830-3. doi:10.1128/AAC.02010-15 [PubMed 26824940]
83. US Department of Health and Human Services (HHS) Panel on Opportunistic Infections in HIV-Infected
Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-
infected adults and adolescents. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed
September 24, 2018.

84. Wallace MR, Bowler WA, Murray NB, Brodine SK, Oldfield EC 3rd. Treatment of adult varicella with oral
acyclovir. A randomized, placebo-controlled trial. Ann Intern Med. 1992;117(5):358-363. [PubMed 1323943]
85. Wilck MB, Zuckerman RA; AST Infectious Diseases Community of Practice. Herpes simplex virus in solid
organ transplantation. Am J Transplant. 2013;13(suppl 4):121-127. doi: 10.1111/ajt.12105. [PubMed
23465005]
86. Wingard JR. Prophylaxis of infection during chemotherapy-induced neutropenia in high-risk adults. Post TW,
ed. UpToDate. Waltham, MA: UpToDate Inc. http://www.uptodate.com. Accessed September 26, 2018.
87. Wong A, Pickering AJ, Potoski BA. Dosing practices of intravenous acyclovir for herpes encephalitis in
obesity: results of a pharmacist survey. J Pharm Pract. 2017;30(3):324-328. doi:
10.1177/0897190016642689 [PubMed 27067742]
88. Wood MJ, Johnson RW, McKendrick MW, Taylor J, Mandal BK, Crooks J. A randomized trial of acyclovir for
7 days or 21 days with and without prednisolone for treatment of acute herpes zoster. N Engl J Med.
1994;330(13):896-900. doi: 10.1056/NEJM199403313301304. [PubMed 8114860]
89. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases
treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137. [PubMed 26042815 ]
90. World Health Organization (WHO). Breastfeeding and maternal medication, recommendations for drugs in
the eleventh WHO model list of essential drugs. 2002.
http://www.who.int/maternal_child_adolescent/documents/55732/en/
91. Zovirax (acyclovir) [prescribing information]. Research Triangle Park, NC: GlaxoSmithKline; January 2019.
92. Zovirax (acyclovir 200 mg, USP) oral suspension [prescribing information]. Morgantown, WV: Mylan
Pharmaceuticals Inc; April 2018.
Topic 15938 Version 328.0

Acyclovir (Systemic) - Pediatric Drug Information - UpToDate PDF

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Acyclovir (Systemic) - Pediatric Drug Information - UpToDate PDF

Uploaded by

Copyright:

Available Formats

16.04.

2020 Acyclovir (systemic): Pediatric drug information - UpToDate

Official reprint from UpToDate®

Acyclovir (systemic): Pediatric drug information

Copyright 1978-2020 Lexicomp, Inc. All rights reserved.

Brand Names: Canada

Body weight <1 kg (Bradley 2015):

PNA ≤14 days: IV: 20 mg/kg/dose every 12 hours

PNA 15 to 28 days: IV: 20 mg/kg/dose every 8 hours

Body weight 1 to 2 kg (Bradley 2015):

PNA ≤7 days: IV: 20 mg/kg/dose every 12 hours

PNA 8 to 28 days: IV: 20 mg/kg/dose every 8 hours

HSV, chronic suppression following any HSV infection:

Initial dosing: Approximate dose: 1,200 to 1,600 mg/m2/dose twice daily

Preterm neonate: Proportional decrease of full-term initial dose

Full term or near term: 400 mg twice daily

Maintenance dosing: In the trial, serum acyclovir concentrations were evaluated to

Varicella (chickenpox), treatment: IV: 10 to 15 mg/kg/dose every 8 hours for 5 to 10 days;

Dosing adjustment in renal impairment: IV:

>50 mL/minute/1.73 m2: No adjustments necessary

25 to 50 mL/minute/1.73 m2: Administer the usual recommended dose every 12 hours

CMV prophylaxis: Low-risk allogeneic hematopoietic stem cell transplant (HSCT) in

Children and Adolescents ≥40 kg: 800 mg 4 times daily

IV: Infants, Children, and Adolescents: 500 mg/m2/dose every 8 hours

Herpes zoster, acute retinal necrosis, treatment (HIV-exposed/-positive):

Infants: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS [pediatric]

Children: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS [pediatric]

Adolescents: 10 to 15 mg/kg/dose every 8 hours for 10 to 14 days (DHHS

Herpes zoster (shingles), treatment:

Hospitalized patient: IV:

Infants: 10 mg/kg/dose every 8 hours for 7 to 10 days (Red Book [AAP

https://www.uptodate.com/contents/acyclovir-systemic-pediatric-drug-information/print?search=aciclovir children&source=panel_search_result&s… 3/34

Children and Adolescents: 500 mg/m2/dose every 8 hours for 7 to 10 days;

Immunocompromised host (non-HIV-exposed/-positive): IV: Infants, Children, and

Mild, uncomplicated disease and no or moderate immune suppression: Oral:

Infants and Children: 20 mg/kg/dose 4 times daily for 7 to 10 days;

Adolescents: 800 mg 5 times daily for 7 to 10 days, longer if lesions resolve

Severe immune suppression or complicated disease; trigeminal nerve

Infants: 10 mg/kg/dose every 8 hours until resolution of cutaneous lesions

Children: 10 mg/kg/dose or 500 mg/m2/dose every 8 hours until resolution

Adolescents: 10 to 15 mg/kg/dose every 8 hours until clinical improvement

Treatment (disseminated, CNS, or skin, eye, or mouth disease): Infants 1 to 3

Chronic suppressive therapy following any neonatal HSV infection:

https://www.uptodate.com/contents/acyclovir-systemic-pediatric-drug-information/print?search=aciclovir children&source=panel_search_result&s… 4/34

AAP Recommendation (low dose, 6-month course): Infants: Oral: 300

Initial dosing: 400 mg twice daily; approximate dose: 1,200 to 1,600

Maintenance dosing: Note: Approximate doses for patients born at term:

Infants 1 to <5 months: 400 mg twice daily

Infants 5 to <9 months: 600 mg twice daily

Infants and Children 9 to <15 months: 800 mg twice daily

Children 15 to 24 months: 1,000 mg twice daily

Note: In the trial, serum acyclovir concentrations were evaluated to

HSV encephalitis, treatment:

Infants and Children 3 months to <12 years:

Non-HIV-exposed/-positive: IV: 10 to 15 mg/kg/dose every 8 hours for 14 to 21

HIV-exposed/-positive: IV: 10 mg/kg/dose every 8 hours for 21 days; higher

HSV genital infection:

First infection, mild to moderate:

Children <12 years: Oral: 40 to 80 mg/kg/day divided in 3 to 4 doses per

Children: Oral: 20 mg/kg/dose 3 times daily for 7 to 10 days; maximum

Adolescents: Oral: 400 mg 3 times daily for 5 to 14 days (DHHS [adult]

Children <12 years (independent of HIV status): Oral: 20 mg/kg/dose 3 times

Children and Adolescents ≥12 years: