Viruses are obligate intracellular parasites.Our arsenal of antivirals is dangerously small.Currently available antivirals are mainly against Herpes,Hepatitis and AIDS viruses.The treatment of HCV has shifted away from the use of Peg-IFN towards oral antivirals.Preventive vaccination is the key to global control of viral infections.

1. ANTIVIRAL THERAPY
DR.RISHIKESAN K.V
SPECIALIST PHYSICIAN
VENNIYIL MEDICAL CENTRE
SHARJAH

2. UNDERSTANDING THE VIRUSES:
THEY ARE DIFFERENT FROM OTHER MICROBES
VIRUSES ARE OBLIGATE INTRACELLULAR PARASITES.
A VIRUS CANNOT REPLICATE ON ITS OWN.
IT MUST ATTACH TO AND ENTER A HOST CELL ,
THEN USES HOST CELL’S ENERGY, METABOLIC ENZYMES, AND
RIBOSOMES TO SYNTHESISE PROTEIN , DNA AND RNA.
THEY CANNOT MAKE ANYTHING OF THEIR OWN. THEY USE THE
HOST CELL’S MATERIALS TO BUILD THEMSELVES.

3. ANTIVIRAL DRUGS: HOW THEY ACT
Key characteristics of antiviral drugs
1.Able to enter the cells infected with virus
2.Interfere with viral nucleic acid synthesis and/or regulation
3.Some drugs interfere with ability of virus to bind to cells
4.Some drugs stimulate the body’s immune system
Best responses to antiviral drugs are in patients with competent
immune systems
A healthy immune system works synergistically with the drug to
eliminate or suppress viral activity

4. HOWEVER ANTIVIRAL THERAPY IS CHALLENGING:
1. Rapid replication of viruses makes it difficult to develop effective
antiviral.
2. Viruses can rapidly mutate and drug becomes ineffective.
3. Difficulty for drug to find virus without injuring normal
cells.(Nonselective inhibitors of virus replication may interfere with host
cell function and result in toxicity.)
4. Antiviral drugs share the common property of being virustatic; they are
active only against replicating viruses and do not affect latent virus.
5. Clinical efficacy depends on achieving inhibitory conc. at
the site of infection within the infected cells

5. WE HAVE GOT A SMALL ARSENAL OF ANTIVIRAL
DRUGS
DESPITE 50 YEARS OF INTENSE
RESEARCH OUR ARSENAL OF
ANTIVIRAL DRUGS REMAIN
DANGEROUSLY SMALL
ONLY ABOUT 30 ANTIVIRAL DRUGS
AVAILABLE IN THE U.S MARKET.
MOSTLY AGAINST HIV AND
HERPES INFECTIONS

6. RESPIRATORY INFECTIONS
THE MOST COMMON VIRAL
INFECTIONS ARE PROBABLY URIs.
SEVERE SYMPTOMS IN INFANTS,
THE ELDERLY AND PATIENTS WITH A
LUNG OR HEART DISEASE.
RESPIRATORY VIRUSES TYPICALLY
SPREAD BY CONTACT WITH
INFECTED RESPIRATORY DROPLETS.
RHINOVIRUS INFECTIONS ARE
UNIVERSAL ESPECIALLY DURING
COLD MONTHS.
NO SPECIFIC THERAPY
NO SPECIFIC PREVENTION
THE RESPIRATORY VIRUSES
INCLUDE:

7. ANTIRESPIRATORY ANTIVIRAL AGENTS
AMANTADINE
RIMANTADINE
ZANAMIVIR
OSELTAMIVIR
RIBAVIRIN
PERAMIVIR

8. ZANAMAVIR AND OSELTAMIVIR
• Indications
• Treament of influenza A
and B within 24-48 hrs of
symptom onset
• Prophylaxis
• Neither drug interferes
with antibody response to
influenza vaccination
Resistance
• Reports appearing
• Incidence may be
increasing

9. VIRAL PNEUMONIA FROM INFLUENZA
A 35 YEAR OLD MALE IN GOOD HEALTH
DEVELOPED FEVER COUGH AND SOB.
ADMITTED TO THE ICU WITH DIFFUSE
INFILTRATES AND HYPOXAEMIA.
HIS RAPID INFLUENZA TEST IS POSITIVE.
WHICH OF THE FOLLOWING HAS BEEN
DEMONSTRATED TO HAVE GOOD
EFFICACY FOR TREATING THIS VIRAL
PNEUMONIA ?
A.OSELTAMIVIR ,
B.ZANAMIVIR,
C.PARAMAVIR ,
D.NONE OF THE ABOVE
A.OSELTAMIVIR ,
B.ZANAMIVIR,
C.PARAMAVIR ,
D.NONE OF THE ABOVE

10. INFLUENZA PNEUMONIA

11. RSV AND HUMAN METAPNEUMOVIRUS
THESE VIRUSES ARE KNOWN TO
PRODUCE
LOWER RESPIRATORY
ILLNESS IN INFANTS AND
MILD UPPER RESPIRATORY
ILLNESS IN ADULTS
RIBAVIRIN IS USED IN
IMMUNOCOMPROMISED
PATIENTS.
Palivizumab IM MONTHLY FOR
CERTAIN INFANTS AT HIGH RISK
OF RSV INFECTION

12. RSV AND HUMAN METAPNEUMOVIRUS
RSV bronchiolitis
Ribavirin
Pharmacology
• Aerosol and oral administration
• Hepatically metabolized and
renally excreted
Major toxicity Anemia
Indications
• Aerosol treatment of RSV in
children
• Effectiveness debated

13. RESPIRATORY SYNCITIAL VIRUS
AEROSOL RIBAVIRIN
UNCERTAIN EFFICACY IN CHILDREN OR ADULTS
ADMINISTRATION BY AEROSOL
2GM. OVER 2 HOURS EVERY 8 HOURS
ADV EFFECTS:
TERATOGENIC FOR PATIENT AND STAFF
HAEMOLYTIC ANAEMIA
BRONCHOSPASM
ALTERNATIVE
PALIVIZUMAB

14. GASTROINTESTINAL INFECTIONS
TRANSMITTED FROM PERSON TO
PERSON BY ORAL FAECAL ROUTE.
ROTAVIRUS : CHILDREN , NOROVIRUS:
OLDER CHILDREN AND ADULTS ,
ASTROVIRUS : USUALLY INFANTS AND
YOUNG CHILDREN , ADENOVIRUS :
INFANTS , CORONA VIRUS – LIKE
AGENTS :INFANTS
MAIN SYMPTOMS : VOMITING AND
DIARRHOEA
NO SPECIFIC TREATMENT , BUT
SUPPORTIVE CARE PARTICULARLY
REHYDRATION IS IMPORTANT
AN EFFECTIVE ROTA VIRUS
VACCINE IS PART OF THE
RECOMMENDED INFANT
VACCINATION SCHEDULE

15. THIS PATIENT PRESENTED WITH CUTANEOUS LESIONS ON THE HANDS,
FEET, AND BUTTOCKS. THE 2- TO 10-MM ERYTHEMATOUS MACULES
DEVELOPED A CENTRAL, GRAY, OVAL VESICLE. THE LESIONS ARE
ELLIPTICAL WITH THE LONG AXIS PARALLEL TO THE SKIN LINES. WHAT
IS THE CAUSE OF THESE SKIN LESIONS?
HMFD is most commonly caused by
coxsackievirus A16 and typically
affects children and infants. HMFD is
highly contagious during the first
week of infection Care is typically
supportive with antipyretics and
anesthetics for symptomatic relief on
a case-by-case basis.

16. CMV INFECTIONS
CMV infection in immunocompetent pt. is often
asymptomatic or manifested as IMN like syndrome (fever,
lymphadenopathy, and atypical lymphocytosis).
In immunocompetent people, infection is usually self-
limiting; therefore, treatment is usually not indicated.
In immunocompromised people (AIDS and transplant
recipients), disease manifests with fever, bone marrow
suppression, pneumonia, hepatitis, colitis, nephritis, and
retinitis.
TREATMENT : IV GANCICLOVIR or oral valganciclovir.

17. TREATMENT OF CMV
RETINITS
Intranuclear inclusions (arrows) found in
cytomegalovirus retinitis. Referred to as owl's
eye because of the dark intranuclear inclusion
surrounded by a clear halo.
Intra-ocular administration of
GANCICLOVIR, and less
commonly fomivirsen, is also used
in CMV retinitis.
IV foscarnet and cidofovir are less
preferred agents.

18. HAV INFECTIONS
• Treatment for HAV infection is primarily supportive, including
appropriate rest when necessary.
• Avoidance of excessive paracetamol and alcohol, and having a balanced
diet are important.
• There are no specific antiviral therapies available.
• Once acute infection occurs, management is largely outpatient-based.
• Rarely, hospitalisation may become necessary for volume depletion,
coagulopathy, or encephalopathy.
• In <1% of patients a fulminant course of illness occurs, characterised by
worsening jaundice and encephalopathy. Prompt referral for
TRANSPLANTATION is warranted in such cases

19. HBV INFECTIONS
Most people are asymptomatic, although some will present
with complications such as cirrhosis, hepatocellular carcinoma,
or liver failure.
Serological markers are essential in making the diagnosis and evaluating
disease activity, including differentiating between people with acute and
chronic infection and chronic asymptomatic carriers.
Therapy for acute infection is almost always supportive care alone.
However, some patients with acute infection may develop liver failure,
and these patients may require referral to liver transplant centre.
Therapy for chronic infection includes nucleoside/nucleotide
analogues, interferon- alfa , and pegylated interferon-alfa .

20. HEPATITIS B
INDICATIONS FOR ANTIVIRALS
PATIENTS WITH ELEVATED
AMINOTRANSFERASE LEVELS
CLINICAL OR BIOPSY EVIDENCE OF
PROGRESSIVE DISEASE OR BOTH
GOAL IS TO ELIMINATE HBV – DNA, TO
PREVENT CIRRHOSIS AND LIVER FAILURE , TO
PREVENT HEPATOCELLULAR CARCINOMA
NEEDS INDEFINITE TREATMENT
EXPENSIVE
RELAPSES ARE COMMON ON STOPPING
TREATMENT PREMATURELY.
TREATMENT MAY BE STOPPED ONCE IF
HBeAg CONVERTS TO anti HBe OR
HBsAg BECOMES NEGATIVE
Hepatitis B is a disease caused by the
hepatitis B virus (HBV), discovered in
1965 . Millions of people worldwide are
infected . Without adequate diagnosis
and treatment, these individuals may
go on to develop liver failure,
hepatocellular carcinoma, or die

21. NIH RECOMMENDATIONS
• The NIH indicates that immediate therapy is not routinely indicated
for patients who have the following :
• Chronic hepatitis B with high levels of serum HBV DNA but normal
serum ALT levels or little activity on liver biopsy (immune-tolerant
phase)
• Low levels of or no detectable serum HBV DNA and normal serum
ALT levels (inactive chronically infected/low replicative phase)
• Positive serum HBV DNA but not HBsAg+ (latent HBV infection),
unless the patient is undergoing immunosuppression

22. 104 - 105COPIES/ML
Therapy is currently recommended for patients with evidence of
chronic active hepatitis B disease (ie, abnormal aminotransferase levels,
positive HBV DNA findings, positive or negative HBeAg.
HBeAg- positive patients with chronic HBV disease
Treatment is advised when the HBV DNA level is at or above 20,000
IU/mL (105copies/mL) and when serum alanine aminotransferase (ALT)
is elevated for 3-6 months.
HBeAg-negative patients with chronic hepatitis B disease
Treatment can be administered when the HBV DNA is at or above 2000
IU/mL (104 copies/mL) and the serum ALT is elevated (ALT levels >20
U/L for females; 30 U/L for males) for 3-6 months.

23. GLOBAL APPROVAL
Currently, Pegylated interferon
alfa (PEG-IFN-a), Entecavir (ETV),
and Tenofovir disoproxil
fumarate (TDF) are the first-line
agents in the treatment of
hepatitis B disease.
These are the main treatment
drugs approved globally for this
disease.
Lamivudine (3TC), telbivudine, and adefovir are
of historical interest. These agents are
currently considered second- or third-line
therapy, or “nonpreferred” treatment.

24. INTERFERONS
Proteins with antiviral,
anti proliferative, and
immunomodulatory effects.
GOOD PROGNOSTIC MARKERS:
High levels of
aminotransferases, A low viral
load, and infection with the wild
type virus .
POOR RESPONDERS:
Asian patients, patients with the
pre core mutant virus .
Pegylated IFN-a 2a
#Enhanced half-life .
#Slow absorption
following subcutaneous
(SC) injection, #Slow renal
clearance, and #Less
immunogenicity .
OTHER INDICATIONS:
Chronic hepatitis C, and
HDV infection.

25. INTERFERON
DOSAGE :
5 MIU sc ONCE/DAY OR 10 MIU sc 3
TMES / WEEK X 16-24 WEEKS.
PEG IFN : DOSAGE:
180mcg BY INJECTION ONCE/WEEK FOR
48WEEKS.
AD.EFFECTS ARE SIMILAR BUT LESS
SEVERE
IN ABOUT 40% OF PTS. THIS REGIMEN
ELIMINATES HBV- DNA ; CAUSES
SEROCONVERSION TO anti- HBe
PEG IFN CAN BE USED
INSTEAD OF IFN IN CASE OF
INTOLERABLE ADVERSE
EFFECTS

26. PREGNANCY AND HBV
Mothers with chronic hepatitis B infection
are often treated in the third trimester if
the serum HBV DNA level is greater than
106 -108 copies/mL, especially if she is
positive for the HBeAg.
For newborns born to mothers with
chronic hepatitis B infection, administer
combined immune- prophylaxis with HBIG
and hepatitis B vaccine within 12 hours of
birth.
Breastfeeding is not contraindicated in
women chronically infected with
hepatitis B if the infant receives HBIG
and vaccine active prophylaxis

27. HCV : APPROACH CONSIDERATIONS
Patients with acute HCV infection appear to have an
excellent chance of responding to 6 months of standard
therapy with IFN. Because spontaneous resolution is
common, no definitive timing of therapy initiation can be
recommended; however, waiting 2-4 months after the onset
of illness seems reasonable. Following acute exposure,
about 55% to 85% of patients develop chronic hepatitis C.
Most infections are asymptomatic; however, hepatic
inflammation is often present and can lead to progressive
hepatic fibrosis

28. THE GOAL OF TREATMENT
Treatment of chronic HCV infection has 2 goals. The
first is to achieve sustained eradication of HCV (ie,
SVR), which is defined as the persistent absence of
HCV RNA in serum 6 months or more after
completing antiviral treatment.
The second goal is to prevent progression to
cirrhosis, hepatocellular carcinoma (HCC), and
decompensated liver disease requiring liver
transplantation.

29. TREATING HEPATITIS C INFECTIONS
• RIBAVIRIN: MAINSTAY FOR
HEPATITIS C TREATMENT
• HIGHLY TERATOGENIC
• ADV.EFFECTS : HAEM.ANAEMIA,
JAUNDICE etc.
• PEG – Interferon alpha 2A
• ADV EFFECTS : FLU LIKE
SYNDROME,
MYALGIAS,LEUKOPAENIA,
ANAEMIA
BOTH DRUGS SHOULD BE INITIATED
IMMEDIATELY UPON DIAGNOSIS AND
TITRES SHOULD BE RECHECKED AT 6
MONTHS, IF POSITIVE DIAGNOSIS IS
CHRONIC HCV

30. RECOMMENDATION
Antiviral therapy should be determined on a case-by-case basis. However,
treatment is widely recommended for patients with elevated serum alanine
aminotransferase (ALT) levels who meet the following criteria :
Age greater than 18 years
Positive HCV antibody and serum HCV RNA test results
Compensated liver disease (eg, no hepatic encephalopathy or ascites)
Acceptable hematologic and biochemical indices (hemoglobin at least 13 g/d L
for men and 12 g/d L for women; neutrophil count >1500/mm 3, serum
creatinine < 1.5 mg/d L)
Willingness to be treated and to adhere to treatment requirements
No contraindications for treatment

31. SHIFTING PARADIGM
The treatment of hepatitis C has evolved over the years.
Initial studies used IFN monotherapy. Subsequently,
combination of ribavirin and IFN or of IFN to which PEG
molecules have been added (ie, PEG-IFN) were used.
Therapy has shifted away from the use of pegylated
interferon towards oral antiviral therapies.
Protease inhibitors have emerged as a third feature of
combination therapy.

32. VIEKIRA PAK
The FDA approved the combination of
Ombitasvir/ Paritaprevir/ Ritonavir and
Dasabuvir for the treatment of GT1 chronic
HCV in adults, including patients with
compensated cirrhosis. This can be used
with or without ribavirin.
The recommended dosing regimen is the
Ombitasvir/ Paritaprevir / Ritonavir fixed-
dose combination 2 tablets once daily plus
Dasabuvir 1 tablet twice daily
VARIOUS
PROTEASE
INHIBITORS HAVE
BEEN USED IN
CHRONIC
INFECTIONS

33. AN ALL ORAL REGIMEN
The FDA approved an all oral
regimen of Simeprevir plus
Sofosbuvir for treatment-naïve
or treatment-experienced
patients. The treatment duration
is 12 weeks for patients without
cirrhosis and 24 weeks for those
with cirrhosis.

34. ACUTE HIV SYNDROME
OCCURS SOON AFTER INFECTION ;
CORRESPONDS WITH A RAPID INCREASE
IN VIRAL LOAD AND A MILD DROP IN CD4
COUNT.
CAN BE ASYMPTOMATIC OR SUBCLINICAL.
SYMPTOMS : OFTEN CONFUSED WITH FLU.
FEVER, MALAISE ,
GEN.LYMPHADENOPATHY AND
MACULOPAPULAR RASH.
DSIS : HIV TESTING (ELISA AND WESTERN
BLOT)
TREATMENT : IF HIV +,TREAT
ACCORDINGLY

35. HAART EFAVIRENZ IS PREFERRED IN
NON PREGNANT WOMEN.
MAY USE 2 NRTIs and 2PIs.
GOAL : THE VIRAL LOAD
SHOULD BE CUT IN HALF IN
THE FIRST MONTH.
IDEALLY IT SHOULD DROP TO
UNDETECTABLE EVENTUALLY.
CD COUNT SHOULD ALSO
RISE.
MONITOR FOR HIV
METABOLIC SYNDROME
ALWAYS 3 OR 4 DRUGS:
SHOULD ALWAYS INCLUDE 2 NRTIs
3rd CAN BE EITHER A PI or AN NNRTI

36. ANTIRETROVIRAL THERAPY
ART has dramatically reduced the mortality associated
with HIV, which can now be considered a chronic
treatable disease.
ART does not, however, cure HIV so treatment is life long
Effective ART reduces the risk of onward transmission of HIV to
sexual partners and mother to child transmission
Antiretroviral therapy can only be initiated once a diagnosis of
HIV is made.
Delayed diagnosis of HIV and delayed initiation of ART can be
associated with increased mortality

37. TREATING THE PATIENT WITH HIV
FIRST A BASELINE WORK UP WHICH
INCLUDES:
• HIV VIRAL GENOTYPING
• CD4 COUNT
• VIRAL LOAD
• TEST FOR TB,CMV,OTHER STDs,
TOXOPLASMA Abs
• CBC , CMP, TFTs, LFTs, LIPIDS
• OPHTHALMOLOGIC EXAM
RECHECK EVERY 3-6 MONTHS
TREATMENT: ANTIRETROVIRALS
START THERAPY WHEN CD4
<350/MICROLITRE OR VIRAL LOAD
>55000
ANTIRETROVIRAL THERAPY GENERALLY BE
STARTED AT CD4 COUNT <350 AND
>200/mm3. 3 or 4 DRUGS REGIMENS
INCLUDING : 2 NRTIs AND EITHER 1 NNRTI
or 1 OR 2 PROTEASE INHIBITORS ARE VERY
EFFECTIVE.
BEFORE STARTING,CLINICIAN SHOULD GET
VIRAL SENSITIVITY TO DETERMINE THE MOST
EFFECTIVE DRUG.

38. RECOMMENDATIONS FROM IAS-USA
ALL PATIENTS WITH CLINICAL
AIDS OR IMMUNOLOGICAL
AIDS (CD4 COUNT <200
CELLS/mm3)
PATIENTS WITH SYMPTOMATIC
HIV DISEASE REGARDLESS OF
CD4 COUNT
PATIENTS WITH CD4 COUNT
LESS THAN OR EQUAL TO 500
CELLS/mm3 with asymptomatic
disease
PATIENTS WITH CD4 COUNT
LESS THAN OR EQUAL TO
500 CELLS/mm3 with
asymptomatic disease
HIV ASSOCIATED
NEPHROPATHY, HBV CO
INFECTION AND
PREGNANCY
HAART

39. HIV AND PREGNANCY
All pregnant women be tested for HIV
infection as early as possible in their
pregnancy .
A negative test does not preclude
diagnosis.
AZT IS RECOMMENDED TO ALL
PREGNANT HIV WOMEN ASAP.
To prevent perinatal HIV transmission,
combination antiretroviral (cART) therapy
is initiated as soon as possible preferably
at 14 weeks gestation ; cART should be
continued in women already on therapy.
LSCS at 38 wks’ gestation for
women with HIV RNA levels >1000
copies/mL, or unknown.
BABY should be on AZT for at least
6 weeks, monitored until 18
months.
NO BREAST FEEDING NEVER,NEVER,
NEVER,NEVER
NO BREAST
FEEDING

40. ANTIRETROVIRAL PROPHYLAXIS
ART RECOMMENDED FOR TREATMENT
OR POST EXP. PROPHYLAXIS.
COMBINATION THERAPY (HAART) IS
ALWAYS RECOMMENDED FOR 4 WEEKS.
THREE DRUGS ARE USUALLY GIVEN
ZDV + LMV+ INV PREVENTS RECEPIENT
INFECTION AFTER ACCIDENTAL
INFUSION OF HIV+ve INFECTED BLOOD.
AZT (ZIDOVUDINE) ITSELF REDUCES RISK
BY 80%

41. HERPES VIRUSES: ANTI-HERPESVIRUS AGENTS
ACYCLOVIR
Valacyclovir
Famciclovir
Ganciclovir
Valganciclovir
Foscarnet
Cidofovir
Formivirsen
Trifluridine
Idoxuridine
Development represents a watershed in the field
of antiviral chemotherapy
Acyclic guanosine analog
Active vs. HSV, VZV and modestly CMV
Mechanism of action
• Preferentially taken up by virally infected cells
• Monophosphorylated by virally encoded thymidine kinases
• Di- and triphosphorylation completed by cellular kinases
• ACV-TP is the active moiety
Competitive inhibitor of viral DNA polymerase
Cellular DNA polymerases much less
susceptible to inhibition
Leads to viral DNA chain termination

42. WHAT IS THE DRUG OF CHOICE FOR
HERPES SIMPLEX ENCEPHALITIS IN AN
IMMUNOLOGICALLY NORMAL 20
YEAR OLD INDIVIDUAL
PREVIOUSLY IN GOOD HEALTH
1.ACYCLOVIR ALONE
2.ACICLOVIR PLUS
CORTICOSTEROIDS
3.GANCICLOVIR
4.FOSCARNET
5.CIDOFOVIR
ACYCLOVIR
ALONE

43. HERPES SIMPLEX ENCEPHALITIS

44. VIRAL ENCEPHALITIS
All cases of suspected CAVE (community-acquired viral
encephalitis) are started empirically on aciclovir until the cause
is determined.
As most cases of sporadic viral encephalitis are secondary to HSV,
this is good clinical practice .
In an immunocompromised patient, CMV encephalitis is a
consideration.
If suspected, Ganciclovir and Foscarnet are given with Aciclovir until
HSV PCR is available. If HSV encephalitis is excluded, then aciclovir
can be discontinued.
In some cases, MRI findings and clinical features strongly
suggest a diagnosis of CMV encephalitis, so aciclovir may not be
necessary.

45. CHICKEN POX
The disease usually resolves
spontaneously over 5-10 days, and Rx.
is generally supportive. Adults and
immunocompromised persons have a
more complicated course than that
occurring in children, and ,the
condition necessitates a more
aggressive approach.
IV acyclovir is recommended for
immunosuppressed
Avoid Aspirin in children
(associated with Reyes
syndrome)
Ibuprofen (
associated with severe
secondary infections).

46. TREATMENT IN THE IMMUNOCOMPROMISED OR
IMMUNOSUPPRESSED
IV Acyclovir therapy is recommended because of the life-threatening
complications of primary varicella infection .
Severe disseminated disease, with the development of varicella
pneumonia, encephalitis, hepatitis, and hemorrhagic complications,
is much more common in this population than in other populations.
Vidarabine, and IFN-alpha are effective in the treatment of primary
varicella infection of immunocompromised hosts. Foscarnet is a
potentially efficacious drug in patients with acyclovir-resistant VZV
strains.

47. TREATMENT IN HEALTHY CHILDREN
The nucleoside analogue
acyclovir (20 mg/kg PO qid for
5 d), though shown to
decrease the symptoms and
duration of primary varicella
infection when administered
within 24 hours of onset of
symptoms, is not commonly
prescribed for otherwise
healthy children.
Given the high risk of varicella-related
complications, children should be treated
if any of the following conditions are a
medical concern:
• Defects in cell-mediated immunity
• Chronic atopic dermatitis
• Chronic asthma
• Iatrogenic immunosuppression
• Long-term systemic steroid use
• Splenic dysfunction
• Nephrotic syndrome

48. IMMUNOCOMPETENT ADULT
Oral acyclovir should be
considered for healthy persons
at increased risk of severe
varicella infections, most
notably patients older than 12
years.
Oral acyclovir therapy in this
population (800 mg 5 times/d
for 7 d), begun within 24 hours
of onset of symptoms, has
been shown to decrease the
duration of lesions and pyrexia,
while reducing other symptoms
and disease duration.
Valacyclovir:
Has higher oral bioavailability.
Used in the treatment of herpes
zoster.
No better efficacy in primary
varicella infection of healthy,
immunocompetent individuals.
Famciclovir is a prodrug of
penciclovir.
Better efficacy in the treatment of
HZ , but it has not been extensively
studied for use in primary varicella
infection of healthy populations.

49. SHINGLES
Keeping in mind the limitations of treatment
effectiveness, antiviral medicines may
be considered for patients with:
• Age > 50 years
• Ophthalmic involvement
• Immunocompromised status
• Atypical presentation of rash, e.g. shingles
affecting the neck, limbs or perineum
• Moderate or severe pain
• Moderate or severe rash

50. HERPES ZOSTER
Oral Aciclovir : first-line antiviral
treatment
Aciclovir 800 mg, 5Xdaily, for 7days.
Valaciclovir is an alternative
antiviral.Valaciclovir have greater overall
effectiveness than Aciclovir as it
produces higher levels of antivirals. May
be a better alternative to aciclovir in
patients at increased risk of
complications.
A meta-analysis of aciclovir Vs aciclovir
with corticosteroids failed to show a
benefit of corticosteroids in improving
QOL or reducing PHN.

51. GENITAL HERPES ?
Your patient is a 24 year
old student who wants to
talk to you about genital
herpes. She had her first
symptomatic infection 3
years ago and tends to get
a recurrence every 6-8
weeks. She has a new
partner and is worried
about passing the virus on
to him.
They have not yet
had sexual
intercourse. She has
read about
suppressive therapy
and would like to
discuss its benefits.
What would be the
most accurate advice
to give her?

52. GENITAL HERPES
Taking suppressive therapy will
reduce but not eliminate the risk
both of symptomatic recurrence and
of passing HSV on to her partner.
Long-term daily suppressive
treatment with oral antivirals is
safe and effectively reduces both
symptomatic recurrences and
the risk of transmission to a
sexual partner.
But it doesn’t
eliminate the
risk of either

53. GENITAL HERPES AND GESTATION
She gets regular outbreaks of genital
herpes and has had these for several years,
although she has not had one so far during
this pregnancy. She is reluctant to take
medication and asks you how likely it is that
she will transmit the HSV infection to her
baby if she does not take suppressive
therapy and has a vaginal delivery.
What should you tell her?
You see a worried
patient who is
22wks. pregnant.

54. GENITAL HERPES
This woman is at risk of a recurrent episodes of genital herpes .
The risk of neonatal infection is low, just 3% even if herpes lesions are
present at the time of labour. The RCOG/BASHH guidance states that daily
suppressive aciclovir can be considered from 36 weeks of gestation .
For those women who do opt for suppressive antiviral
therapy in late pregnancy, a dose of 400 mg three times daily
is recommended.
The risk of neonatal transmission is over 40% in women
who have a first episode of clinically apparent genital herpes
in the last 6 wks. of pregnancy,
Caesarean section is recommended for any woman
who develops a first episode HSV infection in the third
trimester.

55. BELL PALSY: ORGANISM- SPECIFIC THERAPY
Some evidence suggests combination of
antivirals with corticosteroids is more
effective .
HSV-1 or HSV-2 : Prednisone 1 mg/kg or 60
mg/day x 6d, followed by a taper, for a total
of 10d plus Acyclovir 400 mg PO 5 times
daily for10d. or valacyclovir 500 mg PO BID
for 5d.
VZV: Prednisone 1 mg/kg or 60 mg/day for 6
d, followed by a taper, for a total of 10 d plus
Acyclovir 800 mg PO 5 times daily for 10
days or Valacyclovir 1000 mg PO TID for 5d

56. EBV HSV TYPE1
Herpes simplex virus type 1. Primary herpes
can affect the lips, and the ruptured vesicles
may appear as bleeding of the lips.
Mono, like many viral illnesses, just needs to run
its course and it usually resolves without
treatment.
Antiviral drugs are not effective for treating
mono.

57. CONCLUSION
THE ADVANCES MADE IN SPECIFIC TREATMENT OF VIRAL DISEASE
HAVE BEEN ? DISAPPOINTINGLY SLOW IN THE PAST THREE
DECADES.
WE HAVE GOT ONLY A SMALL NUMBER OF ANTIVIRALS WHICH ARE
USEFUL IN A RESTRICTED NUMBER OF CLINICAL SITUATIONS.
MOST ANTIVIRAL DRUGS NON SELECTIVELY INHIBIT VIRUS
REPLICATION WITH SIMULTANEOUSLY INJURING THE HOST CELL,
AND ARE ACCOMPANIED BY SERIOUS SIDE EFFECTS.
POSSIBLE BENEFICIAL EFFECTS OF ANTIVIRAL DRUGS MUST BE
BALANCED AGAINST POTENTIAL IMMUNOSUPPRESSIVE AND
OTHER UNDESIRABLE SIDE EFFECTS.

58. VACCINESANTIVIRALS

59. Field of antiviral therapy has matured dramatically in past
30+ years
Greatest progress made for Herpes viruses, HIV, Respiratory
viruses and Hepatitis viruses
Resistance to any antiviral drug must be anticipated :
Viruses replicate so efficiently
Viruses have modest to high mutation frequencies
Preventive vaccination remains the key to global control of
viral infections
TAKE HOME MESSAGE

61. FOR PATIENT HEARING