Under what circumstances do you consider valacyclovir for the management of VZV disease of the CNS?

If the patient has encephalitis would use IV acyclovir and only transition to high dose valcyclovir (2 g every 8 or every 6 hs depending on weight) after improvement. Although there is PK data to support these high doses, I would not use it initially.

Immunosuppressed patients have a higher likelihood of invasive/disseminated disease. Would be more cautious there, but we have successfully transitioned to oral therapy after 1-2 weeks IV as using IV acyclovir as an outpatient is not easy. moreover, in a patient with encephalitis, the oral option may not be reliable due to changes in mental status.

Having seen ACV nephropathy, we routinely keep all pts, who are on IV ACV, on IV fluid and check daily chem panel. This approach makes conversion to po val-ACV less relevant.