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 likeliho...

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.