Sequential treatment of cytomegalovirus infection or disease with a short course of intravenous ganciclovir followed by oral valganciclovir: efficacy, safety, and pharmacokinetics
ABSTRACT Oral (p.o.) or intravenous (IV) ganciclovir (GCV) has been the first-line agent for prevention and treatment of cytomegalovirus (CMV) infection and disease in solid organ transplantation (SOT). The introduction of p.o. valganciclovir, with higher bioavailability than p.o. GCV, has proven to be a suitable approach toward outpatient p.o. therapy for CMV infection/disease. The present single-arm, exploratory pilot trial performed with 21 patients investigates the efficacy and safety of a short therapeutic course (21 days) based on an initial IV treatment with GCV (5 mg/kg twice daily, for 5 days) followed by p.o. valganciclovir (900 mg twice daily, for 16 days) for CMV infection/disease in SOT patients. In all cases, doses were adjusted for renal function. Moreover, the study allowed comparison of exposure to GCV after p.o. valganciclovir with respect to IV GCV in the same patients. Response to treatment was monitored until day 180. Viral load eradication was achieved in 66.7% of patients, on day 21. Although not statistically significant, a trend was seen toward increased persistence of viral load on day 21 for patients with donor positive/recipient negative CMV serostatus or receiving either anti-rejection therapy or polyclonal anti-thymocyte globulin. CMV clinical infection recurred in 14.3% of patients, with higher recurrence rates in patients with risk factors for persistence of viremia. Exposures to GCV after using IV GCV or p.o. valganciclovir showed comparable values (P=0.054). This short course, combining initial IV GCV and subsequent p.o. valganciclovir, may provide effective exposure and therapeutic response in the treatment of CMV infection in SOT patients with adequate drug exposure and with the additional potential benefit of shortening the length of hospital stay, which may result in cost reduction and improved patient comfort.
SourceAvailable from: Pilar Perez-Romero[Show abstract] [Hide abstract]
ABSTRACT: Objectives The most frequent adverse events associated with valganciclovir treatment are haematological disturbances such as neutropenia. However, the consequences of neutropenia are unknown. We investigated the clinical impact of neutropenia during CMV preemptive therapy and its relationship with the length of antiviral therapy. Methods An observational, prospective cohort of 67 solid organ transplant recipients receiving CMV preemptive therapy was studied. Results Severe neutropenia occurred in 21.8% of the patients at a median of three weeks after initiating antiviral therapy. No association was observed between neutropenia and infection risk in these patients. Liver transplant recipients had 6.7 fold increased risk of neutropenia during CMV therapy compared to kidney transplant recipients (p=0.012). Patients who developed severe neutropenia received antiviral therapy a median of six days longer than patient who did not (p=0.457). Conclusions Despite the frequency of neutropenia during CMV preemptive therapy, the incidence of infections is not increased. Adjusting the length of preemptive therapy during the episodes of viremia may be recommended, especially in patients with concurrent risk factors for neutropenia such as liver recipients. Further trials are warranted to confirm the safety of this approach.Journal of Infection 11/2014; 69(5). DOI:10.1016/j.jinf.2014.07.001 · 4.02 Impact Factor
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ABSTRACT: Cytomegalovirus (CMV) is generally considered the most significant pathogen to infect patients following organ transplantation. Significant improvements have been achieved in the management of CMV disease over recent years, especially since the introduction of oral drugs such as oral ganciclovir followed by valganciclovir (VGC), a prodrug of ganciclovir with enhanced bioavailability. Several randomized controlled trials have shown that VGC is an efficacious and convenient oral drug to prevent or treat CMV disease in solid-organ transplant recipients. In this article, we discuss the clinical and pharmacological experience with the use of VGC for the management of CMV in solid-organ transplant recipients. Finally, novel strategies to further reduce the incidence of CMV disease after transplantation are also reviewed.Expert Review of Anticancer Therapy 11/2011; 9(11):955-65. DOI:10.1586/eri.11.116 · 3.22 Impact Factor
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ABSTRACT: Cytomegalovirus (CMV) is the most frequent infectious complication following solid organ transplantation (SOT). The virus, in this population, is responsible for both direct (viral syndrome, hepatitis, pneumonitis, colitis…) and indirect effects (rejection, infections by other microorganisms and graft dysfunction). In this evidence-based guideline we dealt with the most important aspects of CMV infection in SOT recipients, including pre and post-transplant diagnosis assessment, risk factors with special emphasis in the prevention and treatment of this viral infection. Overall, an adequate management of CMV infection is a critical aspect in transplant patient care. This article is protected by copyright. All rights reserved.Clinical Microbiology and Infection 02/2014; 20. DOI:10.1111/1469-0691.12594 · 4.58 Impact Factor