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DATE: 9 February 2009 CC: Pharmacists UNC is facing a critical shortage of IV acyclovir. We are likely to run out of this drug within the next 7 days, and supplies will not be available for several weeks. Effective immediately the use of IV acyclovir will be closely evaluated by the clinical pharmacists, and may need to be approved by the Pediatric or Adult Infectious Disease Consult Service. Supplies will be apportioned on a first come-first served basis. Alternatives include IV ganciclovir, IV foscarnet, or high dose oral therapy (acyclovir or valacyclovir) depending on clinical presentation and age of the patient. Contact the Pediatric or Adult Infectious Disease Consult Service, the Drug Information Center (966-2373) or the pharmacist covering your service for more specific information. Please see attached treatment recommendations for conserving our dwindling supply of IV acyclovir. Intravenous Acyclovir Shortage Management

Patients with the following infections should be prescribed intravenous acyclovir:
1. Disseminated HSV or VZV infections (including any potential central nervous infection) in ANY
neonate or child under 12 years of age (usual dose is 20 mg/kg IV q8h). 2. Proven HSV or VZV encephalitis (usual acyclovir dose is 10 mg/kg (lean body weight) IV every 8 hours (CrCl > 50 mL/min, dose adjust for CrCl < 50 mL/min). May use one dose for patients with high clinical suspicion of HSV or VZV infections pending results from lumbar puncture for HSV or VZV by PCR technique. 3. Adult patients (including children over 12 years of age) with disseminated HSV or VZV infections that DO NOT involved the central nervous system should be initiated on oral valacyclovir (1
gram orally TID) and/or intravenous ganciclovir (5 mg/kg IV q12h for CrCl > 50 mL/min, dose
adjust for CrCl < 50 mL/min). Usual IV acyclovir dose for immunocompromised adults is 10 to 12
mg/kg (lean body weight) IV every 8 hours (CrCl > 50 mL/min, dose adjust for CrCl < 50 mL/min).

Pharmacy Clinical Specialist and Decentralized Pharmacist Role
1. Evaluate all IV acyclovir orders to determine if the situation is one of the three above indications. 2. Recommend oral valacyclovir for indications stated below 3. If your patient does not conform to the above indications: a. 7am to 5pmÆContact Lindsay Daniels, PharmD, BCPS (pager # 216-2389) for b. 5pm to 7pm ÆVerify and dispense IV acyclovir, and email Lindsay Daniels with patient name, MR#, service, location and dosage. 4. Recommend dosages that conserve the 500 mg vials which are compounded in the IV Room (i.e. 800 mg doses IV q8h, could most likely be converted to 750 mg IV q8h depending on the weight of the patient)
Alternatives to intravenous acyclovir
• Genital herpes simplex: initial episode, 1 g ORALLY twice a day for 7 to 10 days; most effective when started within 48 hr of signs and symptoms • Genital herpes simplex: recurrent episode, 500 mg ORALLY twice a day for 3 days, or 1 g once a day for 5 days; start within 24 hr after onset of signs and symptoms • Genital herpes simplex: recurrent episode, HIV-infected patient, 1 g ORALLY twice a day for 5 to • Herpes labialis: 2 g ORALLY twice a day for 1 day; separate doses by 12 hr; start at the earliest • Herpes zoster: 1 g ORALLY 3 times a day for 7 days; start within 48 hr of the onset of rash A dose of valacyclovir 1 gram orally q8h is equivalent to 5 mg/kg IV q8h
2. Ganciclovir: Consult ID service for dosing recommendations 3. Foscarnet: Consult ID service for dosing recommendations

Source: http://news.unchealthcare.org/archive/unc_physicians_newsletters/Memo-acyclovir-v4.pdf

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