CMV

Anti-CMV Agents

    • Ganciclovir: 5 mg/kg IV q12h x 14-21 days for induction therapy of CMV retinitis, followed by 6 mg/kg IV x 5 days qwk or 5 mg/kg IV q24h; the oral dose is 1 g PO q8h with food.

    • Has activity against HSV and VZV, but safer drugs are available.

    • Widely distributed in the body, including the CSF.

    • Indicated for treatment of CMV retinitis and other serious CMV infections in immunocompromised patients (e.g., transplant and AIDS patients).

    • Chronic maintenance therapy is generally required to suppress CMV disease in patients with AIDS.

    • Adverse events. Neutropenia, may need treatment with GCSF, 300 mcg sc qd-qwk. Thrombocytopenia, rash, confusion, headache, nephrotoxicity, and GI disturbances may also occur.

    • Monitor CBC, electrolytes weekly while patient is receiving therapy.

    • Use of other agents that may be nephrotoxic or bone marrow suppressants may enhance the adverse effects of ganciclovir.

Valganciclovir 900 mg PO q12-24h is the oral prodrug of ganciclovir. It has excellent bioavailability and can be used for treatment of CMV retinitis and, used instead of oral ganciclovir, which has poor oral bioavailability. Adverse events of the same as gangcilovir.

Foscarnet, 60 mg/kg IV q8h or 90 mg/kg IV q12h x 14-21 days as induction therapy, followed by 90-120 mg/kg IV q24h as maintenance therapy for CMV retinitis in patients with AIDS. Can be used in patients who are not tolerating or not responding to ganciclovir.

  • Use for CMV disease in bone marrow transplant patients to avoid bone marrow-suppressive effects of ganciclovir.

  • Used in the treatment of acyclovir-resistant HSV/VZV infections

  • Used for ganciclovir-resistant CMV infections.

  • Adverse events. Nephrotoxicity is major concern.

  • Electrolytes and creatinine clearance determined at baseline, and checked twice a week.

  • Normal saline (500-1000 mL) should Be Given before and during infusions to minimize nephrotoxicity.

  • Foscarnet should be avoided when serum creatinine > 2.8 mg/dL or baseline CrCl of <50 mL/min. Concomitant use of other nephrotoxin (e.g., amphotricin, aminoglycosides, pentamidine, NSAIDs, cisplatin, or cidofovir) should also be avoided.

  • Foscarnet chelates divalent cations and can cause tetany even with normal serum calcium level. Use of foscarnet and pentamidine can cause severe hypocalcemia.

  • On the side effects include seizures, phlebitis, rash, and genital ulcers.

  • Prolonged therapy with foscarnet should be monitored by physician who are experienced with the administration home IV therapy and can systematically monitor patient’s lab results.

Cidofovir, 5 mg/kg IV qwk x 2 wks as induction therapy, followed by 5 mg/kg IV q14d chronically as maintenance therapy for treatment of CMV retinitis in patients with AIDS. Can be given through the PICC line.

  • Adverse events: Nephrotoxicity. Avoid in patients with CrCl <55 mL/min, serum creatinine >1.5 mg/dL, significant proteinuria, or recent history of receiving other nephrotoxic medications.

  • Cidofovir dose must always be administered with probenecid, 2 g PO 3 hours prior to infusion and then 1 g at 2 and 8 hours after the infusion along with 1L normal saline IV 1-2 hrs before the infusion to minimize nephrotoxicity. Check serum creatinine and urine protein before each dose of cidofovir.