Vaccinia immunoglobulin (VIG)
Intravenous VIG is licensed in some countries for the treatment of complications due to vaccinia vaccination (i.e., eczema vaccinatum, progressive vaccinia, severe generalised vaccinia, vaccinia infection in people with skin conditions, aberrant infections induced by vaccinia virus). It is unknown whether people exposed to mpox or with severe mpox would benefit from VIG. It should be used only in a clinical research context with prospective data collection. In the US, VIG can be used for the treatment of mpox under an expanded access protocol in the context of an outbreak. It can also be considered for post-exposure prophylaxis in an exposed person with severe immunodeficiency in T-cell function for which smallpox vaccination following exposure to mpox is contraindicated. It is available upon clinical request to the US Centers for Disease Control and Prevention on a case-by-case basis. VIG may be stockpiled in countries for use during an outbreak.
NIOCH-14, an analogue of tecovirimat, is an investigational oral antiviral agent with in vitro and in vivo activity against orthopoxviruses. Animal challenge studies showed a significant reduction in virus production in the lungs of infected animals when compared with controls. However, the clinical efficacy for the treatment of mpox is uncertain.
Cidofovir is an antiviral agent used intravenously for the treatment of mpox. Topical cidofovir is being investigated as a potential treatment as it may avoid the adverse effects associated with systemic administration (e.g., nephrotoxicity). A small prospective clinical trial demonstrated a statistically significant reduction in the median time to resolution of skin lesions in patients treated with topical cidofovir (used on a compassionate use basis) compared with symptomatic treatment with analgesia. However, local adverse effects (e.g., irritation, erosions) were frequent, especially in the anogenital region. Further research is required.
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