ACEP Monkeypox Field Guide

Currently there is no specific treatment approved for monkeypox virus infections. However, antivirals developed for use in patients with smallpox may prove beneficial.

Persons who should be considered for treatment following consultation with CDC might include:

• Persons with severe disease (e.g., hemorrhagic disease, confluent lesions, sepsis, encephalitis, or other conditions requiring hospitalization)
• Persons who may be at high risk of severe disease:
  • Persons with immunocompromise (e.g., human immunodeficiency virus/acquired immune deficiency syndrome infection, leukemia, lymphoma, generalized malignancy, solid organ transplantation, therapy with alkylating agents, antimetabolites, radiation, tumor necrosis factor inhibitors, high-dose corticosteroids, being a recipient with hematopoietic stem cell transplant <24 months post-transplant or ≥24 months but with graft-versus-host disease or disease relapse, or having autoimmune disease with immunodeficiency as a clinical component)
  • Pediatric populations, particularly patients younger than 8 years of age
  • Pregnant or breastfeeding women
  • Persons with one or more complications (e.g., secondary bacterial skin infection; gastroenteritis with severe nausea/vomiting, diarrhea, or dehydration; bronchopneumonia; concurrent disease or other comorbidities)
• Persons with monkeypox virus aberrant infections that include its accidental implantation in eyes, mouth, or other anatomical areas where monkeypox virus infection might constitute a special hazard (e.g., the genitals or anus).

The following medical countermeasures are currently available from the Strategic National Stockpile (SNS) as options for the treatment of monkeypox:

Tecovirimat (TPOXX):

• Antiviral
• Approved by the FDA (PDF) for the treatment of smallpox in adults and children weighing at least 6.6 pounds.
• CDC holds a special permit that allows for the use of tecovirimat to treat monkeypox during an outbreak.
• Available as a pill or an injection.
• For children who weigh less than 28.6 pounds, the capsule can be opened and medicine mixed with semi-solid food.
• How to Request:
  • CDC, in partnership with FDA, has made it easier to provide tecovirimat (TPOXX) treatment to patients with monkeypox under the EA-IND.
  • The streamlined process allows healthcare providers to start treatment before the paperwork is submitted, and reduces the number of required forms, patient samples, photos, and gives patients the option to see their doctor virtually.
  • To request TPOXX, clinicians and care facility pharmacists can contact their state/territorial health department or CDC (Emergency Operations Center 770-488-7100; Email CDC)
• For additional information see CDC Information for Healthcare Providers on Obtaining and Using TPOXX (Tecovirimat) for Treatment of Monkeypox

Cidofovir (Vistide):

• Antiviral
• Approved by the FDA (PDF) for the treatment of cytomegalovirus (CMV) retinitis in patients with Acquired Immunodeficiency Syndrome (AIDS).
• CDC holds an Expanded Access Investigational New Drug (EA-IND) Protocol status that allows for the use of Cidofovir for the treatment of orthopoxviruses (including monkeypox) in an outbreak.

Vaccinia Immune Globulin Intravenous (VIGIV):

• Licensed by FDA  for the treatment of complications due to vaccinia vaccination including eczema vaccinatum, progressive vaccinia, severe generalized vaccinia, vaccinia infections in individuals who have skin conditions, and aberrant infections induced by vaccinia virus (except in cases of isolated keratitis).
• CDC holds an EA-IND that allows the use of VIGIV for the treatment of orthopoxviruses (including monkeypox) in an outbreak.

Brincidofovir (Tembexa):

• Antiviral medication
• Approved by the FDA (PDF) on June 4, 2021 for the treatment of human smallpox disease in adult and pediatric patients, including neonates.
• CDC is currently developing an EA-IND to help facilitate use of Brincidofovir as a treatment for monkeypox.
• However, Brincidofovir is not currently available from the SNS.

State and territorial health authorities can direct their requests for medical countermeasures for the treatment of monkeypox to the CDC Emergency Operations Center (770-488-7100).