Cytomegalovirus medical therapy

Template:Cytomegalovirus Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

No treatment is generally necessary for CMV infection in the healthy individual since the majority of infections resolve on their own. Antiviral drug therapy is now being evaluated in infants. Ganciclovir treatment is used for patients with depressed immunity who have either sight-related or life-threatening illnesses. Valganciclovir (marketed as Valcyte) is an antiviral drug that is also effective and is given orally. The therapeutic effectiveness is frequently compromised by the emergence of drug-resistant virus isolates. A variety of amino acid changes in the UL97 protein kinase and the viral DNA polymerase have been reported to cause drug resistance. Foscarnet or cidofovir can be given in patients with CMV resistant to ganciclovir, though foscarnet is not as well tolerated as ganciclovir.

Medical Therapy

• Cytomegalovirus treatment

• 1. Immunocompetent patients

• 1.1 Mononucleosis syndrome

• Preferred regimen: supportive therapy

• 1.2 CMV in pregnancy

• Preferred regimen: Hyperimmune 200 IU/kg of maternal weight as single-dose during pregnancy

• 2. Immunocompromised patients

• 2.1 Retinitis

• Preferred regimen (1): Ganciclovir intraocular implant PLUS Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900mg PO qq for maintenance therapy - for immediate sight-threatening lesions
• Preferred regimen (2): Valganciclovir 900 mg PO bid for 14-21 days THEN Valganciclovir 900 mg PO qq for maintenance therapy - for peripheral lesions
• Alternative regimen (1): Foscarnet 60 mg/kg IV q8h OR Foscarnet 90 mg/kg IV q12h for 14-21 days THEN Foscarnet 90-120 mg/kg IV q24h
• Alternative regimen (2): Cidofovir 5 mg/kg IV for 2 weeks THEN Cidofovir 5 mg/kg IV every other week - each dose should be admnistered with IV saline hydration and probenecid
• Alternative regimen (3): Ganciclovir 5 mg/kg IV q12h for 14-21 days THEN Valganciclovir 900 mg PO bid
• Alternative regimen (4): Fomivirsen intravitreal injection - for relapses
• Note: keep a maintenance dose of Valganciclovir 900 mg PO qd until CD4 >100/mm³

• 2.2 Transplant patients

• Preferred regimen: Valganciclovir 900 mg PO bid OR Ganciclovir 5 mg/kg IV q12h for at least 2-3 weeek
• Note: Use Valganciclovir 900 mg PO qd for 1-3 months if high dose of immunosuppression.

• 2.3 Colitis, esophagitis, gastritis

• Preferred regimen: Ganciclovir 5 mg/kg/dose IV q12h for 3-6 weeks weeks for induction. There is no agreement on the use of maintenance.
• Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
• Note: Switch to oral Valganciclovir when PO tolerated & when symptoms not severe enough to interfere with absorption.

• 2.4 Pneumonia

• Preferred regimen: Valganciclovir 900 mg PO bid for 14–21 days, then 900 mg PO qd for maintenance therapy
• Alternative regimen for retinitis: Ganciclovir 5 mg/kg IV q12h for 14–21 days, then Valganciclovir 900 mg PO qd
• Note: In bone marrow transplant patients, combine therapy with CMV immune globulin.

• 2.5 Encephalitis, ventriculitis

• Note: Treatment not defined, but should be considered the same as retinitis. Disease may develop while taking Ganciclovir as suppressive therapy.

• 2.6 Lumbosacral polyradiculopathy

• Preferred regimen: Ganciclovir, as with retinitis
• Alternative regimen: Foscarnet 40 mg/kg IV q12h another option
• Alternative regimen: Cidofovir 5 mg/kg IV for 2 weeks, then 5 mg/kg every other week; each dose should be administered with IV saline hydration and oral probenecid 2 g PO 3h before each dose and further 1 g doses after 2h and 8h.
• Note (1): Switch to Valganciclovir when possible.
• Note (2): Suppression continued until CD4 remains >100/mm³ for 6 months.

• 2.7 Peri/postnatal severe CMV infection in very low birth weight infants

• Preferred regimen: Ganciclovir 6 mg/kg/dose IV q12h for 3 weeks