IDSE Review
What’s New in CMV Prevention and Therapy for Transplant Patients? BY SHMUEL SHOHAM, MD, FIDSA
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nfection and disease caused by the human cytomegalovirus (CMV) remains a challenge in transplant recipients. Two new drugs, letermovir (Prevymis, Merck) and maribavir (Livtencity, Takeda) are now available for prevention and treatment, respectively, of CMV disease. This article reviews the clinical role of these drugs.
Overview Prevention and treatment of CMV disease is a fundamental part of supportive care for recipients of hematopoietic stem cell transplant (HSCT) and solidorgan transplant (SOT). Prevention is mainly by chemoprophylaxis during times of highest risk, such as in the first several months after transplantation and at times of intensification of immunosuppression. CMV serology is helpful for identifying patients at higher risk for clinically significant CMV infection. In HSCT, there is a higher risk for clinically significant CMV infection in recipients who are CMV-seropositive. In SOT, the highest risk is in CMV-seronegative recipients receiving organs from CMV-seropositive donors. Until recently, the drug of choice for prevention of infection has been valganciclovir, which is the
oral prodrug of ganciclovir. Ganciclovir administered intravenously is used when oral therapy is not feasible. Oral ganciclovir is no longer used as it has low bioavailability and is associated with poorer outcomes than other therapies. Treatment of CMV (as opposed to prophylaxis) is given when the level of viremia exceeds a certain numerical threshold (preemptive therapy), when there is viremia with symptoms compatible with CMV infection (CMV syndrome), and when there is evidence for tissue-invasive CMV disease. Treatment is usually with either IV ganciclovir or oral valganciclovir, at doses higher than those used for prophylaxis.1 The main toxicity with valganciclovir and ganciclovir, which henceforth will be referred to as (val)ganciclovir, is bone marrow suppression.2 This predominantly manifests as leukopenia but also can
INFECTIOUS DISEASE SPECIAL EDITION • SPRING 2022
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