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Acyclovir is an agent used to treat infections caused by the herpes simplex virus (HSV). Acyclovir is FDA-approved to treat genital herpes and HSV encephalitis. Non-FDA-approved indications are mucocutaneous HSV, herpes zoster (shingles), and varicella zoster (chickenpox). Acyclovir is the first-line treatment for HSV encephalitis. Currently, no other medications are indicated for treating this condition. It is in the antivirals class of drugs. This activity describes the indications, action, and contraindications for acyclovir as a valuable medication in treating HSV infections. This activity will highlight the mechanism of action, adverse event profile, and other key factors (eg, off-label uses, dosing, pharmacodynamics, pharmacokinetics, monitoring, and clinically relevant drug interactions) pertinent to members of the interprofessional healthcare team in the management of HSV infections. Objectives: Verify dosing and perform medication reconciliation when necessary. Strategize to reduce the potential adverse effect profile of acyclovir. Apply best practices when selecting and modifying treatment regimens using acyclovir. Collaborate with the interprofessional when initiating and monitoring acyclovir to enhance patient care. Access free multiple choice questions on this topic.

Acute kidney injury (AKI) is the most significant adverse effects of parenteral acyclovir administration. The incidence of AKI is comparable to other nephrotoxic medications such as aminoglycosides. Patients with CKD are at higher risk. Dose adjustment of acyclovir for ideal body weight and baseline renal function is imperative.[25] A study regarding the pharmacokinetics of acyclovir demonstrated that a patient's glomerular filtration and tubular secretion contribute to its renal excretion.[26] Also, a recent retrospective case-control study over 4 years showed a statistically significant association between obesity and nephrotoxicity (odds ratio 3.2, 95% CI 1.19 to 8.67). Similarly, and not surprisingly, researchers observed a similar association between those receiving concomitant vancomycin (odds ratio 4.73, 95% CI, 1.57 to 14.25). Appropriate cautions are necessary when administering intravenous acyclovir to such higher-risk patients.[27] Acyclovir treatment can cause acute kidney injury because of acyclovir crystal formation in the renal tubules. Yalçinkaya R. et al studied risk factors for acyclovir-induced acute kidney injury in children.[28] The retrospective study had a total of 472 patients. Thirty-two had acute kidney injury—most patients presented with no symptoms. Risk factors were older age, obesity, current use of nephrotoxic drugs, higher baseline creatinine concentrations, higher dose, and longer duration of acyclovir use.

Administering intravenous acyclovir requires interprofessional effort and communication. It is not a benign drug, having potential adverse effects such as phlebitis, hypersensitivity, and AKI. Therefore, pharmacists, prescribing clinicians (MDs, DOs, NPs, and PAs), and nurses must work together to achieve adequate and nontoxic dosing and monitor therapy. Clinicians will make the initial decision to use acyclovir. Dose adjustments for ideal body weight and baseline renal function are necessary. The pharmacist should coordinate this with nurses and clinicians for inpatients, verifying dosing and performing medication reconciliation. Also, patients must monitor signs/symptoms of hypersensitivity and phlebitis, specifically at the infusion site; this is where nurses will be best positioned to inform the rest of the healthcare team should there be any issues of concern. Interprofessional teamwork among each healthcare provider can help minimize and prevent the adverse effects of intravenous administration of acyclovir.[25] Interprofessional coordination and collaboration among physicians, NPs, PAs, specialists, pharmacists, nurses, and public health professionals can enhance patient outcomes when using acyclovir therapy in treating viral infections. [Level 5]