作者:Daniel T. Leung、Stephen L. Sacks
DOI:10.2165/00003495-200060060-00007
日期:2000.12
The incidence of genital herpes continues to increase in epidemic-like fashion. Aciclovir (acyclovir) has been the original gold standard of therapy. The recent addition of famciclovir and valaciclovir as antiherpes drugs has improved convenience as well as the efficacy of treatment. Although aciclovir remains a widely prescribed and reliable drug, its administration schedule falls short of the ease of usage that the newer nucleoside analogues offer, for both episodic and suppressive therapy. Suppression of symptomatic disease and asymptomatic shedding from the genitalia have both become popular approaches, if not the primary targets of antiviral therapy. Knowing that asymptomatic disease leads to most cases of transmission strongly suggests that suppression with antiviral agents could reduce transmission risk in discordant couples. Unfortunately, the role for antivirals in reducing transmission remains to be proven in clinical trials. Neonatal herpes is now successfully treated using aciclovir. Current randomised clinical trials are examining aciclovir and valaciclovir administration, as well as safety and efficacy for post-acute suppressive therapy. Prevention of recurrences in pregnancy is also a topic under investigation, with a view to reducing the medical need for Cesarean section, or alternatively (and far less likely to be accomplished) to protect the neonate. Although resistance is largely limited to the immunocompromised and a change in resistance patterns is not expected, several drugs are available for the treatment of aciclovir-resistant strains of herpes simplex. Foscarnet is the main alternative with proven efficacy in this setting. Unfortunately, administration of foscarnet requires intravenous therapy, although a single anecdote of topical foscarnet efficacy in this setting has been published. Alternatives include cidofovir gel, which is not commercially available but can be formulated locally from the intravenous preparation. Less effective alternatives include trifluridine and interferon. Future possibilities for treatment of genital herpes include a microparticle-based controlled-release formulation of aciclovir and resiquimod (VML-600; R-848). The search for an effective therapeutic vaccine for genital herpes has not been successful to date, although a live virus glycoprotein H-deficient (DISC) vaccine is currently in clinical trials. Recent data suggest that seronegative women are protected (albeit, not fully) by a glycoprotein D recombinant vaccine with adjuvant. Despite the established safety and convenience of current treatment options, better suppressive options and topical treatment options are much needed. Studies using existing agents as potential tools to avoid Cesarean section, or transmission to neonate or partner are ongoing. Both vaccines and antivirals may eventually play a role in prevention of infection.
生殖器疱疹的发病率继续以流行病的方式增加。阿昔洛韦(aciclovir)一直是治疗的原始金标准。近期,法莫昔洛韦(famciclovir)和瓦尔阿昔洛韦(valaciclovir)作为抗疱疹药物的加入提升了治疗的便利性和疗效。尽管阿昔洛韦依然是一种广泛处方和可靠的药物,但其给药方案不如新一代核苷类似物在发作性和抑制性治疗方面的使用方便。抑制有症状的疾病和无症状的生殖器病毒排泄已成为流行的治疗方法,甚至成为抗病毒治疗的主要目标。考虑到无症状疾病是大多数传播案例的根源,这强烈表明使用抗病毒药物进行抑制治疗可能会降低不一致伴侣之间的传播风险。不幸的是,目前尚需临床试验证实抗病毒药物在减少传播中的作用。新生儿疱疹目前已成功使用阿昔洛韦进行治疗。当前的随机临床试验正在研究阿昔洛韦和瓦尔阿昔洛韦的给药,及其在急性后抑制治疗中的安全性和疗效。预防妊娠期间复发也是一个正在研究的话题,旨在减少剖宫产的医疗需求,或者(较不可能实现的)保护新生儿。尽管抗药性主要限于免疫系统受损的患者,且抗药性模式不太可能发生变化,但目前有几种药物可用于治疗阿昔洛韦耐药型单纯疱疹。福赛那特(foscarnet)是这一领域主要的替代药物,并已证明其有效性。不幸的是,福赛那特的给药需要通过静脉治疗,尽管已经有关于局部福赛那特在此情况下有效性的单个案例报告。其他替代品包括cidofovir凝胶,虽然市面上没有供应,但可以通过静脉制剂在当地制备。不太有效的替代药物包括三氟尿嘧啶和干扰素。未来生殖器疱疹的治疗可能包括基于微球的阿昔洛韦和瑞克莫德的控释制剂(VML-600;R-848)。迄今为止寻找有效的生殖器疱疹治疗疫苗尚未成功,尽管一种缺乏糖蛋白H的活病毒疫苗(DISC)目前在进行临床试验。最新数据显示,阴性血清女性在一定程度上受到含佐剂的糖蛋白D重组疫苗的保护(尽管并非完全)。尽管现有治疗选项已确立其安全性和便利性,但仍迫切需要更好的抑制选项和局部治疗方案。目前有研究正在使用现有药物作为潜在工具,以避免剖宫产或向新生儿或伴侣传播感染。疫苗和抗病毒药物最终可能在预防感染中发挥作用。