Cytomegalovirus infection medical therapy: Difference between revisions
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==Overview== | ==Overview== | ||
== | ==Medical Therapy== | ||
[[Antiviral drugs|Antiviral therapy]] is the primary modality of treatment. Duration of therapy and the [[Antiviral Therapy|antiviral agents]] are selected based on the severity of the disease, location of the disease and the level of [[immunosuppression]]. | |||
===CMV Retnitis=== | |||
The choice of therapy is based on the location of the lesions and level of [[immunosuppression]] of the patient. Systemic antiviral therapy is preferred as infection rate of the contralateral eye is reduced. | |||
*'''Initial Therapy for patients with immediate sight-threatening lesions''' (Adjacent to the [[optic nerve]] or [[fovea]]) | |||
**Preferred Regimen(1): [[Ganciclovir]] intraocular implant + [[valganciclovir]] 900 mg PO (BID for 14–21 days, then once daily) {{and}} One dose of intravitreal [[ganciclovir]] may be administered immediately after diagnosis until [[ganciclovir]] implant can be placed | |||
**Alternate Regimen (1): [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily {{or}} | |||
**Alternate Regimen (2): [[Ganciclovir]] 5 mg/kg IV q12h for 14–21 days, then [[valganciclovir]] 900 mg PO daily {{or}} | |||
**Alternate Regimen (3): [[Foscarnet]] 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h {{or}} | |||
**Alternate Regimen (4): [[Cidofovir]] 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and [[probenecid]] 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g) | |||
***Note(1): This regimen should be avoided in patients with [[sulfa allergy]] because of cross [[hypersensitivity]] with [[probenecid]]. | |||
***Note(2): If systemic anti-CMV treatment is not available, use sequential [[ganciclovir]] intravitreal injections until immune reconstitution in response to [[HIV AIDS medical therapy|anti retroviral viral therapy]] is achieved. | |||
*'''For Small Peripheral Lesions''' | |||
**Preferred Regimen: [[Valganciclovir]] 900 mg PO BID for 14–21 days, then 900 mg PO daily {{and}} One dose of intravitreal [[ganciclovir]] may be administered immediately after diagnosis to deliver high local concentration until systemic [[ganciclovir]] concentration is reached. | |||
*'''Chronic Maintenance Therapy (Secondary Prophylaxis) for CMV Retinitis''' | |||
**The drug of choice for chronic maintenance therapy and the preferred route (i.e., [[implant]], [[Intravitreal administration|intravitreal]] injection, [[Intravenous therapy|IV]], oral, or combination; and which [[drug]]) should be made in consultation with an ophthalmologist. Considerations should include the anatomic location of the retinal lesion, vision in the contralateral eye, the patient’s immunologic and virologic status and response to [[HIV AIDS medical therapy|antiretroviral therapy]]. | |||
**Patients with sight-threatening [[retinitis]] will most benefit from [[ganciclovir]] implant to control [[retinitis]] progression, due to the delivery of high concentration of [[ganciclovir]] at the site of infection. | |||
***Preferred Regimen (1): [[Valganciclovir hydrochloride|Valganciclovir]] 900 mg PO daily + [[ganciclovir]] intraocular implant (for sight-threatening retinitis) {{or}} | |||
***Preferred Regimen (2): [[Valganciclovir]] 900 mg PO daily (for small peripheral lesions) {{and}} | |||
***Note(1): [[Ganciclovir]] intraocular implant should be replaced every 6–8 months until sustained immune recovery is documented. | |||
***Alternate Regimen (1): [[Ganciclovir]] 5 mg/kg IV 5–7 times weekly {{or}} | |||
***Alternate Regimen (2): [[Foscarnet]] 90–120 mg/kg IV once daily {{or}} | |||
***Alternate Regimen (3): [[Cidofovir]] 5 mg/kg IV every other week with [[saline]] hydration and [[probenecid]] as above. | |||
*'''Immune Restoration Uveitis (IRU)''' | |||
**Preferred Regimen (1): Periocular [[corticosteroid]] or a short course of systemic steroid | |||
*'''Stopping Chronic Maintenance Therapy for CMV Retinitis''' | |||
**[[CMV]] treatment for at least 3–6 months, with [[CD4]] count >100 cells/mm3 for >3 to 6 months in response to [[AIDS antiretroviral drugs|ART]]. | |||
**Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of [[CD4]] count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring. | |||
**Routine (i.e., every 3 months) ophthalmologic follow-up is recommended for early detection of [[relapse]] or immune restoration uveitis, and then annually after [[Immune reconstitution syndrome|immune reconstitution]]. | |||
*'''Reinstituting Chronic Maintenance/Secondary Prophylaxis for CMV Retinitis''' | |||
**[[CD4]]+ count <100 cells/mm³ | |||
===CMV Colitis and Esophagitis=== | |||
Duration of therapy: 21–42 days or until signs and symptoms have resolved | |||
*Preferred Regimen (1): [[Ganciclovir]] 5 mg/kg IV q12h, may switch to [[valganciclovir]] 900 mg PO q12h once the patient can absorb and tolerate PO therapy. | |||
*Alternate Regimen (1): [[Foscarnet]] 60 mg/kg IV q8h or 90 mg/kg IV q12h for patients with treatment limiting toxicities to [[ganciclovir]] or with [[ganciclovir]] resistance {{or}} | |||
*Alternate Regimen (2): Oral [[valganciclovir]] may be used if symptoms are not severe enough to interfere with oral absorption {{or}} | |||
: | *Alternate Regimen (3): For mild cases: If [[HIV AIDS medical therapy|ART]] can be initiated or optimized without delay, withholding [[Cytomegalovirus|CMV]] therapy may be considered. | ||
**Note (1): Maintenance therapy is usually not necessary, but should be considered after relapses. | |||
===CMV Pneumonitis=== | |||
*Doses are the same as for [[CMV]] [[retinitis]]. | |||
*Treatment experience for [[CMV]] [[pneumonitis]] in [[HIV]] patients is limited. Use of IV [[ganciclovir]] or IV [[foscarnet]] is reasonable. | |||
*The role of oral [[valganciclovir]] has not been established. | |||
*The duration of therapy has not been established. | |||
===Neurologic Disease=== | |||
*Doses are the same as for [[Cytomegalovirus|CMV]] [[retinitis]]. | |||
*Treatment should be initiated promptly. | |||
*Combination of [[ganciclovir]] [[Intravenous therapy|IV]] + [[foscarnet]] [[IV]] to stabilize disease and maximize response; continue until symptomatic improvement | |||
*Continue therapy until resolution of neurologic symptoms | |||
*Optimize [[HIV AIDS medical therapy|ART]] to achieve viral suppression and [[Immune reconstitution syndrome|immune reconstitution]] | |||
==References== | ==References== | ||
Revision as of 15:07, 16 May 2017
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Cytomegalovirus infection Microchapters |
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Differentiating Cytomegalovirus infection from other Diseases |
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Cytomegalovirus infection medical therapy On the Web |
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American Roentgen Ray Society Images of Cytomegalovirus infection medical therapy |
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Risk calculators and risk factors for Cytomegalovirus infection medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Medical Therapy
Antiviral therapy is the primary modality of treatment. Duration of therapy and the antiviral agents are selected based on the severity of the disease, location of the disease and the level of immunosuppression.
CMV Retnitis
The choice of therapy is based on the location of the lesions and level of immunosuppression of the patient. Systemic antiviral therapy is preferred as infection rate of the contralateral eye is reduced.
- Initial Therapy for patients with immediate sight-threatening lesions (Adjacent to the optic nerve or fovea)
- Preferred Regimen(1): Ganciclovir intraocular implant + valganciclovir 900 mg PO (BID for 14–21 days, then once daily) AND One dose of intravitreal ganciclovir may be administered immediately after diagnosis until ganciclovir implant can be placed
- Alternate Regimen (1): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then 5 mg/kg IV daily OR
- Alternate Regimen (2): Ganciclovir 5 mg/kg IV q12h for 14–21 days, then valganciclovir 900 mg PO daily OR
- Alternate Regimen (3): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for 14–21 days, then 90–120 mg/kg IV q24h OR
- Alternate Regimen (4): Cidofovir 5 mg/kg/week IV for 2 weeks, then 5 mg/kg every other week with saline hydration before and after therapy and probenecid 2 g PO 3 hours before the dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g)
- Note(1): This regimen should be avoided in patients with sulfa allergy because of cross hypersensitivity with probenecid.
- Note(2): If systemic anti-CMV treatment is not available, use sequential ganciclovir intravitreal injections until immune reconstitution in response to anti retroviral viral therapy is achieved.
- For Small Peripheral Lesions
- Preferred Regimen: Valganciclovir 900 mg PO BID for 14–21 days, then 900 mg PO daily AND One dose of intravitreal ganciclovir may be administered immediately after diagnosis to deliver high local concentration until systemic ganciclovir concentration is reached.
- Chronic Maintenance Therapy (Secondary Prophylaxis) for CMV Retinitis
- The drug of choice for chronic maintenance therapy and the preferred route (i.e., implant, intravitreal injection, IV, oral, or combination; and which drug) should be made in consultation with an ophthalmologist. Considerations should include the anatomic location of the retinal lesion, vision in the contralateral eye, the patient’s immunologic and virologic status and response to antiretroviral therapy.
- Patients with sight-threatening retinitis will most benefit from ganciclovir implant to control retinitis progression, due to the delivery of high concentration of ganciclovir at the site of infection.
- Preferred Regimen (1): Valganciclovir 900 mg PO daily + ganciclovir intraocular implant (for sight-threatening retinitis) OR
- Preferred Regimen (2): Valganciclovir 900 mg PO daily (for small peripheral lesions) AND
- Note(1): Ganciclovir intraocular implant should be replaced every 6–8 months until sustained immune recovery is documented.
- Alternate Regimen (1): Ganciclovir 5 mg/kg IV 5–7 times weekly OR
- Alternate Regimen (2): Foscarnet 90–120 mg/kg IV once daily OR
- Alternate Regimen (3): Cidofovir 5 mg/kg IV every other week with saline hydration and probenecid as above.
- Immune Restoration Uveitis (IRU)
- Preferred Regimen (1): Periocular corticosteroid or a short course of systemic steroid
- Stopping Chronic Maintenance Therapy for CMV Retinitis
- CMV treatment for at least 3–6 months, with CD4 count >100 cells/mm3 for >3 to 6 months in response to ART.
- Therapy should be discontinued only after consultation with an ophthalmologist, taking into account magnitude and duration of CD4 count increase, anatomic location of the lesions, vision in the contralateral eye, and the feasibility of regular ophthalmologic monitoring.
- Routine (i.e., every 3 months) ophthalmologic follow-up is recommended for early detection of relapse or immune restoration uveitis, and then annually after immune reconstitution.
- Reinstituting Chronic Maintenance/Secondary Prophylaxis for CMV Retinitis
- CD4+ count <100 cells/mm³
CMV Colitis and Esophagitis
Duration of therapy: 21–42 days or until signs and symptoms have resolved
- Preferred Regimen (1): Ganciclovir 5 mg/kg IV q12h, may switch to valganciclovir 900 mg PO q12h once the patient can absorb and tolerate PO therapy.
- Alternate Regimen (1): Foscarnet 60 mg/kg IV q8h or 90 mg/kg IV q12h for patients with treatment limiting toxicities to ganciclovir or with ganciclovir resistance OR
- Alternate Regimen (2): Oral valganciclovir may be used if symptoms are not severe enough to interfere with oral absorption OR
- Alternate Regimen (3): For mild cases: If ART can be initiated or optimized without delay, withholding CMV therapy may be considered.
- Note (1): Maintenance therapy is usually not necessary, but should be considered after relapses.
CMV Pneumonitis
- Doses are the same as for CMV retinitis.
- Treatment experience for CMV pneumonitis in HIV patients is limited. Use of IV ganciclovir or IV foscarnet is reasonable.
- The role of oral valganciclovir has not been established.
- The duration of therapy has not been established.
Neurologic Disease
- Doses are the same as for CMV retinitis.
- Treatment should be initiated promptly.
- Combination of ganciclovir IV + foscarnet IV to stabilize disease and maximize response; continue until symptomatic improvement
- Continue therapy until resolution of neurologic symptoms
- Optimize ART to achieve viral suppression and immune reconstitution