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Tan CA, Palen L, Su Y, Li Y, Gennarelli RL, Perales MA, Cohen N, Papanicolaou GA, Shah GL, Seo SK. Impact of Primary Letermovir Prophylaxis Versus Preemptive Antiviral Therapy for Cytomegalovirus on Economic and Clinical Outcomes after Hematopoietic Cell Transplantation. Transplant Cell Ther 2024:S2666-6367(24)00434-2. [PMID: 38838781 DOI: 10.1016/j.jtct.2024.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/22/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Preemptive therapy (PET) historically has been the primary strategy to reduce early-onset cytomegalovirus (CMV) reactivation after allogeneic hematopoietic cell transplantation (HCT) but is associated with antiviral-associated toxicities and increases in healthcare resource utilization and cost. Despite its high cost, letermovir (LTV) prophylaxis has largely supplanted PET due to its effectiveness and tolerability. Direct comparisons between LTV and PET approaches on economic and clinical outcomes after allogeneic HCT remain limited. Objective: To compare total cost of care (inpatient and outpatient) between LTV prophylaxis and PET through day+180 after allogeneic HCT. Adult allogeneic CMV seropositive (R+) HCT recipients who initiated LTV <30 days after HCT between 01/01/18 and 12/31/18 were matched 1:1 to allogeneic CMV R+ HCT recipients between 01/01/15 and 12/31/17 (PET cohort). Patients were grouped into high-risk (HR) or standard-risk (SR) for CMV to compare the LTV and PET cohorts. Direct costs for each patient's index HCT admission and all subsequent inpatient and outpatient care through day+180 after HCT were determined and converted into 2021 US dollars and then to Medicare proportional dollars (MPD). A secondary analysis using 2019 average wholesale price was conducted to specifically evaluate anti-CMV medication costs. There were a total of 176 patients with 54 HR CMV pairs and 34 SR CMV pairs. No differences in survival between LTV and PET for both HR and SR CMV groups were observed. The rate of clinically significant CMV infection decreased for both HR CMV (11/54, 20.4% versus 38/54, 70.4%, P < .001) and SR CMV (1/34, 2.9% versus 12/34, 35.3%, P < .001) patients who were given LTV prophylaxis with corresponding reductions in val(ganciclovir) and foscarnet (HR CMV only) use. Among HR CMV patients, LTV prophylaxis was associated with reductions in CMV-related readmissions (3/54, 5.6% versus 18/54, 33.3%, P < .001) and outpatient visits within the first 100 days after HCT (20 versus 25, P = .002), and a decreased median total cost of care ($36,018 versus $75,525, P < .001) in MPD was observed. For SR CMV patients on LTV, a significant reduction in the median inpatient cost ($15,668 versus $27,818, P < .001) was found, but this finding was offset by a higher median outpatient cost ($26,145 versus $20,307, P = .030) that was not CMV-driven. LTV prophylaxis is highly effective in reducing clinically significant CMV reactivations for both HR and SR HCT recipients. In this study, LTV prophylaxis was associated with a decreased total cost of care for HR CMV patients through day+180. Specifically, reductions in CMV-related readmissions, exposure to CMV-directed antiviral agents, and outpatient visits in the first 100 days after HCT were observed. SR CMV patients receiving LTV prophylaxis benefited by having a reduced inpatient cost of care due to lowered room and pharmacy costs.
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Affiliation(s)
- Carrie A Tan
- Department of Pharmacy, City of Hope National Medical Center, Duarte, California
| | - Lauren Palen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York; Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yiqi Su
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Yuxuan Li
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | - Miguel-Angel Perales
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Nina Cohen
- Department of Pharmacy, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Genovefa A Papanicolaou
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Gunjan L Shah
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Susan K Seo
- Infectious Disease Service, Memorial Sloan Kettering Cancer Center, New York, New York; Department of Medicine, Weill Cornell Medical College, New York, New York.
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Gan GG, Iyadorai T, Sulaiman NY, Hussein N, Ariffin H. Clinical and Economic Impact of CMV Infection in Allogeneic Hematopoietic Stem Cell Transplantation: Perspectives from a Middle-Income Nation. Clin Transplant 2024; 38:e15375. [PMID: 39031785 DOI: 10.1111/ctr.15375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 04/23/2024] [Accepted: 05/30/2024] [Indexed: 07/22/2024]
Abstract
BACKGROUND Cytomegalovirus infection (CMV) is a common complication after allogeneic hematopoietic stem cell transplantation (AHSCT). CMV infection increases transplantation costs; however, the extent of the financial burden may vary in different countries. This study aims to determine the clinical and economic impact of CMV infection in patients undergoing AHSCT in a middle-income country. METHODS A total of 150 adult and pediatric patients post-AHSCT were included for analysis. In addition to incidence of CMV infections, data on graft versus host disease (GVHD) were also collected. Standard hospital charges for AHSCT and any additional transplantation-related expenditure within 12 months were also retrieved in 104 patients. RESULTS CMV infection, acute GVHD and chronic GVHD occurred in 38.7%, 60.7%, and 22.0% of patients, respectively. Patients with CMV infections had higher readmission rates compared to those who did not (67.2% vs. 47.8%; p = 0.020). Additional expenditure was seen in HLA-haploidentical AHSCT and CMV infection (MYR11 712.25/USD2 504.49; p < 0.0001 and MYR5 807.24/USD1 241.79; p = 0.036), respectively. CONCLUSION This single-center study demonstrated that patients who underwent HLA-haploidentical AHSCT and subsequently developed CMV infection had higher transplantation expenditures compared to those who had matched-related transplantation. Further studies should be conducted to evaluate if primary prophylaxis against CMV is cost-effective, especially in patients who undergo HLA-haploidentical AHSCT.
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Affiliation(s)
- Gin Gin Gan
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Thevambiga Iyadorai
- Department of Medical Microbiology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Noor Yuhyi Sulaiman
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Najihah Hussein
- Department of Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
| | - Hany Ariffin
- Department of Pediatrics, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia
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Włodarczyk M, Wieczorkiewicz-Kabut A, Białas K, Koclęga A, Noster I, Zielińska P, Helbig G. Real-Life Data on the Efficacy and Safety of Letermovir for Primary Prophylaxis of Cytomegalovirus in Allogeneic Hematopoietic Stem Cell Recipients: A Single-Center Analysis. Turk J Haematol 2024; 41:9-15. [PMID: 38345092 PMCID: PMC10918401 DOI: 10.4274/tjh.galenos.2024.2024.0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 02/11/2024] [Indexed: 03/05/2024] Open
Abstract
Objective Cytomegalovirus (CMV) reactivation is a life-threatening complication after allogeneic hematopoietic stem cell transplantation (HSCT). Introduction of letermovir (LMV) seems to improve post-transplant outcomes, but delayed-onset CMV reactivation still remains a challenge. In this study, we report on our first experience with LMV prophylaxis in 93 CMV-seropositive adult patients receiving HSCT in our center. Materials and Methods We retrospectively analyzed the data of 93 adult CMV-seropositive recipients receiving LMV as CMV prophylaxis after HSCT for hematological malignancies between 2019 and 2023. The starting LMV dose was 480 mg daily, reduced to 240 mg daily for those receiving cyclosporin A co-administration. CMV DNA in the blood was measured by real-time polymerase chain reaction weekly for the first 2 months after transplantation, then every other week until the end of immunosuppressive treatment. LMV was continued to day +100 or to CMV reactivation. Results The median recipient age at the time of transplant was 51 (range: 20-71) years. All patients received grafts from peripheral blood, mostly for acute myeloid leukemia (60%). The median time from transplantation to LMV initiation was 3 (range: 0-24) days. While 55% of patients were transplanted from matched related donors, 32% had unrelated donors and 13% underwent haploidentical HSCT. Four patients (4%) had CMV “blips” while on LMV, but the drug was continued and repeated assays were negative. Only 2 patients (2%) experienced CMV reactivation while on LMV, on days 48 and 34 after HSCT, respectively. Seven patients (7%) developed late-onset CMV reactivation after a median of 124 days after HSCT (range: 118-152 days) and they were successfully treated with ganciclovir. CMV disease was not observed. Grade III-IV acute graft-versus-host disease occurred in 6 patients (6%) during LMV treatment. LMV treatment was free of side effects. Conclusion LMV prophylaxis was effective in preventing CMV reactivation with a favorable safety profile. CMV reactivation occurred mostly after LMV discontinuation; thus, extending the duration of prophylaxis beyond 100 days could be beneficial.
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Affiliation(s)
- Martyna Włodarczyk
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Agata Wieczorkiewicz-Kabut
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Krzysztof Białas
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Anna Koclęga
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Izabela Noster
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Patrycja Zielińska
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
| | - Grzegorz Helbig
- Medical University of Silesia, Faculty of Medicine in Katowice, Department of Hematology and Bone Marrow Transplantation, Katowice, Poland
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Roberts MB, Kotton CN. Letermovir Prophylaxis After Kidney Transplantation: Another Tool but Not a Revolution Yet. Transplantation 2024; 108:7-9. [PMID: 38098156 DOI: 10.1097/tp.0000000000004809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Affiliation(s)
- Matthew B Roberts
- Infectious Diseases Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Camille N Kotton
- Infectious Diseases Division, Department of Medicine, Massachusetts General Hospital, Boston, MA
- Department of Medicine, Harvard Medical School, Boston, MA
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Malagola M, Radici V, Farina M, Pellizzeri S, Spoldi F, Morello E, Polverelli N, Buttini EA, Bernardi S, Re F, Leoni A, Signorini L, Caruso A, Russo D. CMV prophylaxis with letermovir significantly improves graft and relapse free survival following allogeneic stem cell transplantation. Bone Marrow Transplant 2024; 59:138-140. [PMID: 37857841 PMCID: PMC10781629 DOI: 10.1038/s41409-023-02124-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/25/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Michele Malagola
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.
| | - Vera Radici
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Mirko Farina
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Simone Pellizzeri
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Filippo Spoldi
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Enrico Morello
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Nicola Polverelli
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Eugenia Accorsi Buttini
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Simona Bernardi
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-oncologico AIL (CREA), "ASST-Spedali Civili" Hospital, Brescia, Italy
| | - Federica Re
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-oncologico AIL (CREA), "ASST-Spedali Civili" Hospital, Brescia, Italy
| | - Alessandro Leoni
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
- Centro di Ricerca Emato-oncologico AIL (CREA), "ASST-Spedali Civili" Hospital, Brescia, Italy
| | - Liana Signorini
- Unit of Infectious and Tropical Diseases, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Arnaldo Caruso
- Institute of Microbiology, Department of Molecular and Translational Medicine, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Domenico Russo
- Blood Diseases and Cell Therapies Unit, Bone Marrow Transplant Unit, "ASST-Spedali Civili" Hospital of Brescia; Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
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Moore WJ, Boutin CA, Tanna S. A new direction for cytomegalovirus prophylaxis among transplant recipients: Benefits and nonviral outcomes of letermovir use as primary CMV prophylaxis. Curr Opin Infect Dis 2023; 36:514-521. [PMID: 37773928 DOI: 10.1097/qco.0000000000000983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
PURPOSE OF REVIEW Letermovir has changed the game of primary prophylaxis against cytomegalovirus (CMV) for hematopoietic stem cell transplant (HSCT) and more recently, solid organ transplant recipients. This is largely due to letermovir's similar efficacy in protecting against CMV reactivation and disease, along with its superior safety profile, notably reduced myelotoxicity, and lack of renal dose adjustment compared to standard agents like valganciclovir. This review will describe the potential benefits and clinical considerations of letermovir as prophylaxis among transplant recipients, with a focus on recent evidence describing nonviral outcomes of CMV. RECENT FINDINGS Recent evidence has demonstrated improved safety (e.g., less myelosuppression) and tolerability with no difference in rates of CMV infection or disease in kidney transplant recipients given letermovir compared to valganciclovir. Real-world studies and meta-analyses in HSCT populations have explored various nonviral outcomes with letermovir use. Letermovir prophylaxis was associated with reduced mortality, lower rates of graft versus host disease, delayed CMV immune reconstitution, improved tolerability with extended durations, and decreased healthcare utilization. SUMMARY Letermovir is an effective antiviral agent for CMV prevention and has demonstrated enhanced safety, which may allow for extended durations of primary prophylaxis among transplant recipients along with other improved clinical outcomes by mitigating the indirect effects of CMV.
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Affiliation(s)
- W Justin Moore
- Department of Pharmacy, Northwestern Medicine, Chicago, Illinois, USA
| | - Catherine-Audrey Boutin
- Division of Infectious Disease, Department of Medicine, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Sajal Tanna
- Division of Infectious Disease, Department of Medicine, Inova Medical Group, Falls Church, Virginia, USA
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