Outbreaks while on valacyclovir - please help!

[SammieSammie]

Hello Sir,

I recently posted a question related to autoinnoculation and very much appreciated your advice and guidance.

I am 16 weeks pregnant and have had HSV2 for about 7 years. I have been on valacyclovir on and off for about 5 years. I have had recurrent outbreaks during my pregnancy and was recently put on daily suppression of 500mg, with an increase to 1000mg during an outbreak. This occurred because I had three outbreaks pretty much back-to-back. Each only lasted 3-4 days but had a other one to take it place.

Yesterday, a recent outbreak had just about healed (the source of my autoinnoculation question) and yesterday was the forth day of 1000mg valacyclovir daily. However, yesterday afternoon I noticed what I thought were prodrome symptoms, which I didn't worry about (and thought I was wrong) because I had been on the larger dose of medication. However, low and behold, I woke up in the early hours of this morning with itching and the definite start of a new outbreak, near, but not the same, place, as the one that just healed.

I am at my wit's end. Is it unusual to have ANOTHER outbreak after 4 days of the medication? Or breakthrough outbreaks on the medication in general? I was having outbreaks on daily suppression of 500mg but it surprises me that this outbreak occurred after 4 days of the higher dose. Is my immune system so low due to the pregnancy?

Also, my research suggests that these recurrent outbreaks do not harm the baby in-utero because the cycle of the virus is through the nerves towards the base of my spine and back again, and not through my blood circulation, thus it does not reach the baby. Is this the case? I am aware of the requirements closer to the birth about outbreaks, but it seems that a c-section is in order if the medication can't control the outbreaks.

Your guidance is appreciated Sir,

Sincerely,

Sammie

[Edward W Hook, MD]

I'm pleased I could help. EWH

[SammieSammie]

Thank you Dr. Your help and this forum has been very useful. I live in England (UK) and sometimes feel a bit isolated with this problem. But you have given me (and my unborn son!!) much comfort.

Sincerely,

Sammie Lynn

[Edward W Hook, MD]

.
There is no reason to worry that taking your vitamins and valacyclovir at the same time might interfer with the effectiveness of each other.  Please do not worry about this as a possible cause of your recent recurrences.  EWH

[SammieSammie]

Hello Sir's,

I am still waiting for proper results, but the Doctor is fairly certain this outbreak was again HSV2. I am now on daily suppression, which I have been on in the past, even during this pregnancy. We will also be discussing a plan for different supplements that may help.

It has just occurred to me that I have been taking the valtrex and my prenatal vitamins at the same time each day, and have done in the past also. Perhaps this is my OCD but is this a problem? It never occurred to me to take them at different times and I am a bit concerned. I can't really find anything about this and forgot to ask the OB.

Many thanks again,

Anita

[Edward W Hook, MD]

Thanks.  We look forward to hearing the results of your tests.  EWH

[SammieSammie]

Thank you so much for your time Dr HHH and EWH. Many apologies for the double posting...I wasn't sure which forum to post on, so I hedged my bets and went with both!

I took your advice Dr HHH, and have an appointment this afternoon while the lesion is still new. I am fairly certain that is what it is due to the normal herpetic pain underneath and in the general area yesterday, itching last night and then here it is now. However, the repeat outbreaks are driving me crazy so I will see what to do and how much medication I need to be taking, all with the little person in mind.

Thank you both for your responses. I wasn't sure about building a resistance to the medication. If it is rare and that is what has happened, well that is unfortunate and other arrangements will be made for my delivery. However, I am pleased that these outbreaks just affect me due to the nerve cycle, and not the baby.

I will let you know the outcome if that is okay.

Sincerely,

Sammie

[H. Hunter Handsfield, M.D.]

Welcome back.  Dr. Hook and I don't normally comment on each others discussions.  However, in this case I had mistakenly viewed your identical question on the gyn forum, thinking I was looking at this one.  See my reply there.  You will see that Dr. Hook and I agree with one another, although I didn't mention the possibility of drug resistance to the virus -- which, as Dr. Hook says, is very rare.

Sorry if there is any confusion from the dual reply.

[Edward W Hook, MD]

Welcome back. Today I will be answering your question.  In preparing to do so, I reviewed your earlier interaction with Dr. Handsfield.  I agree with you that to have had so many recurrences so quickly is a bit unusual.  There are several possibilities.  One possibility is that this is simply bad luck.  As you know, suppressive therapy reduces the frequency and duration of recurrences but does not prevent recurrences.  Your pregnancy may also be contributing to this.  In pregnancy your immune system is affected in subtle ways and, as a result, may do a slightly less effective job in holding your infection in check.  Finally, your herpes virus may have developed resistance to valacyclovir and related drugs.  This is not a common occurrence but does occur.  Your doctor, or perhaps an in infectious diseases expert can help you test the virus cultured from a lesion to check for this.  If this is the case, this does not represent a danger to you or your child and taking a "holiday" from suppressive therapy often restores sensitivity to valacyclovir therapy (this is a complex issue forgive me for not going into more detail- the science and management approach is quite complex.  

Finally, regarding your second question, you are correct, your recurrences do not represent a major risk to your child as recurrences are processes that occur with reactivation at the nerve roots, not systemically.

I hope these comments are helpful.  EWH