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Ye Z, Yang Y, Ke W, Li Y, Wang K, Chen M. Overview and update on cytomegalovirus-associated anterior uveitis and glaucoma. Front Public Health 2023; 11:1117412. [PMID: 36935679 PMCID: PMC10014866 DOI: 10.3389/fpubh.2023.1117412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 02/08/2023] [Indexed: 03/06/2023] Open
Abstract
Cytomegalovirus anterior uveitis is the most common ocular inflammatory disease caused by cytomegalovirus infection. It mainly occurs in middle-aged males with competent immunologic function, and the incidence is higher in Asia. The clinical manifestations vary from Posner-Schlossman syndrome and corneal endotheliitis to Fuchs uveitis syndrome, and are often accompanied by intraocular hypertension. Secondary glaucoma is a potentially blinding ocular complication with a pathogenesis that includes complicated immunological factors, intraocular inflammation, different types of angle abnormalities, and the administration of steroids, which may result in physical discomfort and visual impairment. Diagnostic tests, such as the polymerase chain reaction, optical coherence tomography, ocular microscopy, and confocal microscopy, might help in identifying anterior uveitis caused by other viruses. Combinations of antiviral medications and anti-inflammatory agents are effective treatments. If pharmacological therapy cannot reduce intraocular pressure or slow the progression of glaucomatous optic neuropathy, surgical intervention is required as a last resort.
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Affiliation(s)
- Zifan Ye
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Yumei Yang
- Shangyu People's Hospital of Shaoxing, Shaoxing, China
| | - Weishaer Ke
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Yuhang Li
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
| | - Kaijun Wang
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
- Kaijun Wang
| | - Min Chen
- Eye Center of the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
- Zhejiang Provincial Key Lab of Ophthalmology, Hangzhou, China
- *Correspondence: Min Chen
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Chen WB, Long Z, Hou J, Miao H, Zhao MW. Continuous High-Dose (6 mg) vs. Low-Dose (3 mg) Intravitreal Ganciclovir for Cytomegalovirus Retinitis After Haploidentical Hematopoietic Stem Cell Transplantation: A Randomized Controlled Study. Front Med (Lausanne) 2022; 8:750760. [PMID: 35004721 PMCID: PMC8739491 DOI: 10.3389/fmed.2021.750760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 11/29/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose: To evaluate the safety and efficacy of continuous high-dose (6 mg) intravitreal ganciclovir injections (IVG) for cytomegalovirus (CMV) retinitis (CMVR) after haploidentical hematopoietic stem cell transplantation (Haplo-HSCT), and to explore factors that may influence the treatment procedure. Design: Prospective, randomized, single-blinded, positive-controlled, interventional, comparative study. Methods: A total of 22 patients with CMVR (32 eyes) were randomized to either high-dose group (IVG 6 mg weekly) or low-dose group (IVG 3 mg given twice weekly for 2 weeks as induction phase and weekly thereafter as maintenance phase). Patients who were recorded any positive CMV DNAemia or other active CMV diseases and needed systemic anti-CMV treatment during the study period were excluded. The vision outcome, variables of the treatment procedure, and incidence of complication and CMVR recurrence were analyzed and compared. Logistic regression was applied to determine the factors that may have an impact on the treatment process at baseline. Results: Compared to the low-dose group, the high-dose group resulted in a median of two less intravitreal injections (4 vs. 6 times, respectively, P = 0.016), while the rate of vision stability or improvement (81.2 vs. 87.5%), the incidence of complication (6.2 vs. 18.8%), and CMVR recurrence (12.5% vs. 6.2%) were similar (all P > 0.05). No drug-related toxicity was observed. Initial aqueous CMV-DNA load (OR: 6.872, 95% CI: 1.335–35.377, P = 0.021) and extension of lesion (OR: 0.942, 95% CI: 0.897 to .991, P = 0.020), but not dosing regimen (P = 0.162), were predictors of the treatment duration. Conclusions: Continuous high-dose regimen was well tolerated and resulted in less intravitreal injections, with similar vision outcomes and safety profiles. The clinical course of CMVR after Haplo-HSCT was determined by its own nature at baseline and could not be modified by treatment protocols under consistent immune background.
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Affiliation(s)
- Wei-Bin Chen
- Department of Ophthalmology and Clinical Center of Optometry, Peking University People's Hospital, Beijing, China.,Eye Diseases and Optometry Institute, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China.,College of Optometry, Peking University Health Science Center, Beijing, China
| | - Ze Long
- Department of Ophthalmology and Clinical Center of Optometry, Peking University People's Hospital, Beijing, China.,Eye Diseases and Optometry Institute, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China.,College of Optometry, Peking University Health Science Center, Beijing, China
| | - Jing Hou
- Department of Ophthalmology and Clinical Center of Optometry, Peking University People's Hospital, Beijing, China.,Eye Diseases and Optometry Institute, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China.,College of Optometry, Peking University Health Science Center, Beijing, China
| | - Heng Miao
- Department of Ophthalmology and Clinical Center of Optometry, Peking University People's Hospital, Beijing, China.,Eye Diseases and Optometry Institute, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China.,College of Optometry, Peking University Health Science Center, Beijing, China
| | - Ming-Wei Zhao
- Department of Ophthalmology and Clinical Center of Optometry, Peking University People's Hospital, Beijing, China.,Eye Diseases and Optometry Institute, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory of Diagnosis and Therapy of Retinal and Choroid Diseases, Beijing, China.,College of Optometry, Peking University Health Science Center, Beijing, China
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Ho SA, Slavin M, Roberts JA, Yong M. Optimization of Ganciclovir use in allogeneic hematopoietic cell transplant recipients - the role of therapeutic drug monitoring. Expert Rev Anti Infect Ther 2020; 19:707-718. [PMID: 33201745 DOI: 10.1080/14787210.2021.1851193] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Introduction: Cytomegalovirus (CMV) is an opportunistic infectious complication that can occur after allogeneic hematopoietic cell transplantation (HCT). The mainstay of treatment and prevention of this infection is ganciclovir and its ester prodrug valganciclovir. There is conflicting evidence on the clinical utility of routine ganciclovir therapeutic drug monitoring (TDM) as a means to optimize treatment.Areas covered: This review aims to describe the current knowledge of the pharmacokinetic and pharmacodynamic characteristics of ganciclovir and valganciclovir, and to explore the evidence and challenges surrounding ganciclovir TDM within the allogeneic HCT cohort.Expert opinion: Ganciclovir TDM is important to optimize efficacy in selected patient groups where there are variable pharmacokinetic factors or inadequate response to treatment. However, defined pharmacokinetic exposures which correlate with treatment efficacy and toxicity remain elusive. Prospective clinical studies in specific patient groups are required to clarify this issue. Alternative TDM targets such as the intracellular ganciclovir triphosphate should be explored as they may prove to have better correlation with clinical outcomes and adverse effects. With recent advances in CMV immune monitoring, novel approaches integrating TDM with specific CMV immune phenotyping in a predictive model will be advantageous in optimizing ganciclovir dosing by combining TDM with a risk stratification approach.
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Affiliation(s)
- Su Ann Ho
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia
| | - Monica Slavin
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine & Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, Australia.,Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Michelle Yong
- Departments of Infectious Diseases, The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre Melbourne, Australia.,Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, Australia.,Victorian Infectious Diseases Services Department, Royal Melbourne Hospital, Parkville VIC, Australia
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Abdul-Aziz MH, Alffenaar JWC, Bassetti M, Bracht H, Dimopoulos G, Marriott D, Neely MN, Paiva JA, Pea F, Sjovall F, Timsit JF, Udy AA, Wicha SG, Zeitlinger M, De Waele JJ, Roberts JA. Antimicrobial therapeutic drug monitoring in critically ill adult patients: a Position Paper .. Intensive Care Med 2020; 46:1127-1153. [PMID: 32383061 PMCID: PMC7223855 DOI: 10.1007/s00134-020-06050-1] [Citation(s) in RCA: 471] [Impact Index Per Article: 117.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/10/2020] [Indexed: 12/12/2022]
Abstract
Purpose This Position Paper aims to review and discuss the available data on therapeutic drug monitoring (TDM) of antibacterials, antifungals and antivirals in critically ill adult patients in the intensive care unit (ICU). This Position Paper also provides a practical guide on how TDM can be applied in routine clinical practice to improve therapeutic outcomes in critically ill adult patients.
Methods Literature review and analysis were performed by Panel Members nominated by the endorsing organisations, European Society of Intensive Care Medicine (ESICM), Pharmacokinetic/Pharmacodynamic and Critically Ill Patient Study Groups of European Society of Clinical Microbiology and Infectious Diseases (ESCMID), International Association for Therapeutic Drug Monitoring and Clinical Toxicology (IATDMCT) and International Society of Antimicrobial Chemotherapy (ISAC). Panel members made recommendations for whether TDM should be applied clinically for different antimicrobials/classes. Results TDM-guided dosing has been shown to be clinically beneficial for aminoglycosides, voriconazole and ribavirin. For most common antibiotics and antifungals in the ICU, a clear therapeutic range has been established, and for these agents, routine TDM in critically ill patients appears meritorious. For the antivirals, research is needed to identify therapeutic targets and determine whether antiviral TDM is indeed meritorious in this patient population. The Panel Members recommend routine TDM to be performed for aminoglycosides, beta-lactam antibiotics, linezolid, teicoplanin, vancomycin and voriconazole in critically ill patients. Conclusion Although TDM should be the standard of care for most antimicrobials in every ICU, important barriers need to be addressed before routine TDM can be widely employed worldwide. Electronic supplementary material The online version of this article (10.1007/s00134-020-06050-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mohd H Abdul-Aziz
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia
| | - Jan-Willem C Alffenaar
- School of Pharmacy, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia.,Westmead Hospital, Westmead, NSW, Australia.,Marie Bashir Institute of Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa, Genoa and Hospital Policlinico San Martino - IRCCS, Genoa, Italy
| | - Hendrik Bracht
- Department of Anaesthesiology, University Ulm, Ulm, Germany
| | - George Dimopoulos
- Department of Critical Care, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Deborah Marriott
- Department of Microbiology and Infectious Diseases, St. Vincent's Hospital, Sydney, NSW, Australia
| | - Michael N Neely
- Department of Paediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.,Division of Infectious Diseases, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Jose-Artur Paiva
- Department of Medicine, Faculty of Medicine of Porto, Porto, Portugal.,Department of Emergency and Intensive Care Medicine, Centro Hospitalar Universitario de São João, Porto, Portugal
| | - Federico Pea
- Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUFC, Udine, Italy
| | - Fredrik Sjovall
- Department of Perioperative Medicine, Skåne University Hospital, Malmö, Sweden
| | - Jean F Timsit
- Department of Intensive Care Medicine and Infectious Diseases, Bichat-Claude Bernard University Hospital, AP-HP, Paris, France.,Infection, Antimicrobials, Modelling, Evolution (IAME), Paris Diderot University, Paris, France
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Sebastian G Wicha
- Department of Clinical Pharmacy, Institute of Pharmacy, University of Hamburg, Hamburg, Germany
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jan J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research (UQCCR), Faculty of Medicine, The University of Queensland, Brisbane, QLD, 4029, Australia. .,Department of Intensive Care Medicine and Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia. .,Centre for Translational Anti-infective Pharmacodynamics, School of Pharmacy, The University of Queensland, Brisbane, QLD, Australia. .,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France.
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Mortari APG, Amaral BP, Oliveira PSD, Dotto EK, Flores MM, Cargnelutti JF, Weiblen R, Flores EF. Ganciclovir attenuates the respiratory disease induced by Equid alphaherpesvirus 1 in rabbits. PESQUISA VETERINARIA BRASILEIRA 2019. [DOI: 10.1590/1678-5150-pvb-6353] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
ABSTRACT: Equid alphaherpesvirus 1 (EHV-1) is an important pathogen of horses, associated with respiratory, neurological disease and abortions. As vaccination is not always effective, anti-herpetic therapy may represent an alternative to prevent the losses caused by the infection. We herein investigated the activity of ganciclovir (GCV), an anti-herpetic human drug, in rabbits experimentally infected with EHV-1. Thirty-days-old New Zealand rabbits were allocated in three groups (6 animals each) and submitted to different treatments: G1 (non-infected controls), G2 (inoculated with EHV-1) - 107 TCID50 intranasally - IN) and G3 (inoculated IN with EHV-1 and treated with GCV - 5mg/kg/day for 7 days) and monitored thereafter. All animals of G2 developed systemic signs (moderate to severe apathy, anorexia), ocular discharge and respiratory signs (serous to mucopurulent nasal discharge), including mild to severe respiratory distress. Viremia was detected in all rabbits of G2 for up to 11 days (mean duration = 6.5 days). One animal died after severe respiratory distress and neurological signs (bruxism, opistotonus). In addition, these animals gained less weight than the control (G1) and GCV-treated rabbits (G3) from days 4 to 14pi (p<0.05). The clinical score of rabbits of G2 was statistically higher than the other groups from days 3 to 6pi (p<0.05), demonstrating a more severe disease. In contrast, G3 rabbits did not present systemic signs, presented only a mild and transient nasal secretion and gained more weight than G2 animals (p<0.05). In addition, viremia was detected in only 3 rabbits and was transient (average of 2.3 days). Thus, administration of GCV to rabbits inoculated IN with EHV-1 resulted in an important attenuation of the clinical disease as demonstrated by full prevention of systemic signs, maintenance of weight gain and by drastic reduction in viremia and in the magnitude of respiratory signs. These results are promising towards further testing of GCV as a potential drug for anti-herpetic therapy in horses.
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Affiliation(s)
- Ana Paula G. Mortari
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | - Bruna P. Amaral
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | - Pablo S.B. De Oliveira
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | - Evelyn K. Dotto
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | - Mariana M. Flores
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | | | - Rudi Weiblen
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
| | - Eduardo F. Flores
- Universidade Federal de Santa Maria, Brazil; Universidade Federal de Santa Maria, Brazil
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Relationship of Ganciclovir Therapeutic Drug Monitoring with Clinical Efficacy and Patient Safety. Antimicrob Agents Chemother 2019; 63:AAC.01855-18. [PMID: 30602515 DOI: 10.1128/aac.01855-18] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 12/20/2018] [Indexed: 12/25/2022] Open
Abstract
The clinical utility of ganciclovir therapeutic drug monitoring (TDM) is unknown. We retrospectively analyzed adult patients treated for cytomegalovirus (CMV) infection with ganciclovir with TDM between 2005 and 2015. The primary outcome was an association between ganciclovir TDM and clinical efficacy endpoints within 30 days, defined by viral load and symptomatology. Secondary outcomes included safety endpoints, evaluated within 7 days of the last administered dose of ganciclovir. Of 175 patients evaluated, 82 patients with CMV infection were included in our analysis with a median (interquartile range) baseline CMV viral load of 5,500 (3,000 to 15,200) copies/ml. The majority achieved undetectable or reduced CMV viral load below the lower limit of quantification (74.4%) with improvement in symptomatology (70.7%) at 30 days. Among patients with detectable CMV viremia at 30 days, the viral load had declined to a median of 1,000 (1,000 to 3,090) copies/ml. We did not observe significant associations between the efficacy outcomes and ganciclovir trough (P = 0.20 and P = 0.20, respectively) or peak concentrations (P = 0.14 and P = 0.14, respectively). Similarly, there was no significant association between ganciclovir trough or peak concentrations and safety endpoints, including leukopenia (P = 0.48 and P = 0.69), neutropenia (P = 0.59 and P = 0.69), thrombocytopenia (P = 0.29 and P = 0.37), anemia (P = 0.51 and P = 0.35), nephrotoxicity (P = 0.41 and P = 0.57), and neurotoxicity (P = 0.22 and P = 0.48). We did not observe any associations between ganciclovir TDM and clinical efficacy or safety endpoints. Routine ganciclovir TDM may be of limited value. Future studies may be warranted to identify specific populations with unpredictable pharmacokinetic and pharmacodynamics profiles in whom ganciclovir TDM may be of benefit.
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Kloker LD, Berchtold S, Smirnow I, Schaller M, Fehrenbacher B, Krieg A, Sipos B, Lauer UM. The Oncolytic Herpes Simplex Virus Talimogene Laherparepvec Shows Promising Efficacy in Neuroendocrine Cancer Cell Lines. Neuroendocrinology 2019; 109:346-361. [PMID: 31280274 DOI: 10.1159/000500159] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 04/04/2019] [Indexed: 01/17/2023]
Abstract
Metastatic neuroendocrine cancer still constitutes a palliative situation, lacking promising treatment options. Oncolytic virotherapy, a novel type of virus-based immunotherapy, lyses tumor cells using genetically engineered viruses thereby activating the immune system to induce an optimized antitumor response which could bring down tumor masses to a stage of minimal residual tumor disease. The oncolytic vector talimogene laherparepvec (T-VEC, herpes simplex virus [HSV] type 1) has already shown excellent safety profiles in clinical studies and has become the first ever FDA/EMA-approved oncolytic virus (OV). This work presents a first preclinical assessment of this state-of-the-art OV, using a panel of human neuroendocrine tumor/neuroendocrine carcinoma (NET/NEC) cell lines. Cytotoxicity, transgene expression, and viral replication patterns were studied. Furthermore, the antiproliferative activity was compared to the one of mTOR inhibitor Everolimus and also interactions between the OV and Everolimus were evaluated. Moreover, virostatic effects of ganciclovir (GCV) on replication of T-VEC were assessed and electron microscopic pictures were taken to comprehend viral envelopment and details of the replication cycle of T-VEC in human neuroendocrine cancer. It could be shown that T-VEC infects, replicates in, and lyses human NET/NEC cells exhibiting high oncolytic efficiencies already at quite low virus concentrations. Interestingly, Everolimus was not found to have any relevant impact on rates of viral replication, but no additive effects could be proved using a combinatorial therapy regimen. On the other hand, GCV was shown to be able to limit replication of T-VEC, thus establishing an important safety feature for future treatments of NET/NEC patients. Taken together, T-VEC opens up a promising novel treatment option for NET/NEC patients, warranting its further preclinical and clinical development.
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Affiliation(s)
- Linus D Kloker
- Department of Clinical Tumor Biology, University Hospital, University of Tübingen, Tübingen, Germany
| | - Susanne Berchtold
- Department of Clinical Tumor Biology, University Hospital, University of Tübingen, Tübingen, Germany
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Tübingen, Germany
| | - Irina Smirnow
- Department of Clinical Tumor Biology, University Hospital, University of Tübingen, Tübingen, Germany
| | - Martin Schaller
- Department of Dermatology, University Hospital, University of Tübingen, Tübingen, Germany
| | - Birgit Fehrenbacher
- Department of Dermatology, University Hospital, University of Tübingen, Tübingen, Germany
| | - Andreas Krieg
- Department of Surgery (A), Heinrich-Heine-University and University Hospital Düsseldorf, Düsseldorf, Germany
| | - Bence Sipos
- Department of Clinical Tumor Biology, University Hospital, University of Tübingen, Tübingen, Germany
| | - Ulrich M Lauer
- Department of Clinical Tumor Biology, University Hospital, University of Tübingen, Tübingen, Germany,
- German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Tübingen, Germany,
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Wang X, Wang L, Wu N, Ma X, Xu J. Clinical efficacy of oral ganciclovir for prophylaxis and treatment of recurrent herpes simplex keratitis. Chin Med J (Engl) 2015; 128:46-50. [PMID: 25563312 PMCID: PMC4837818 DOI: 10.4103/0366-6999.147808] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Herpes simplex keratitis (HSK) caused by herpes simplex virus 1 (HSV-1), which has high recurrent rate and incidence of severe vision loss, is the leading cause of infectious blindness in the world. The aim was to explore the clinical efficacy of oral ganciclovir (GCV) in the prevention of recurrent HSK. Methods: A multicenter, prospective, randomized, single-blind, and controlled clinical trial was conducted from April 2010 to June 2013. One hundred seventy-three patients (173 eyes involved) who were diagnosed as recurrent HSK definitely, including stromal keratitis and corneal endotheliitis, were divided into three groups randomly: negative control (placebo) group was topically administered with 0.15% GCV ophthalmic gel, 4 times per day and 0.1% fluorometholone eye drops, 3 times per day until resolution of HSK; positive control acyclovir (ACV) group was topically adopted the same ophthalmic gel and eye drops and additionally received oral ACV 400 mg 5 times a day for 10 weeks and followed by 400 mg 2 times per day for 6 months; test GCV group was topically adopted the same treatment as negative control group and additionally received oral GCV 1000 mg 3 times per day for 8 weeks. The symptoms and signs were evaluated before and after the therapy 1st week, 2nd week and then followed up every 2 weeks until recovery. Furthermore, we followed up recurrence of HSK for every 3 months after recovery and then assessed the cure time, recurrent rate and adverse reactions. Results: One hundred and seventy-three patients were followed up 7–48 months (mean 32.1 ± 12.3 months), but 34 patients were failed to follow-up. The cure time was 12.1 ± 4.3, 11.9 ± 4.0 weeks in negative control (placebo) group and positive control ACV group respectively (P = 0.991), which was longer than that in test GCV group (8.6 ± 2.8 weeks) and there was a significant difference between test GCV group and negative control (placebo) group or positive control ACV group (P = 0.000). Furthermore, the recurrent rate was higher in negative control (placebo) group (47.3%) than that in positive control group ACV (26.7%) and test GCV group (17.2%), and there was a great significant difference among the three groups (P = 0.007), but there was no significant difference between positive control ACV group and test GCV group (P = 0.358). In addition, there was no obvious adverse reaction expect neutropenia (only one patient in test GCV group). Conclusion: Short-term oral GCV could cure recurrent HSK and endotheliitis, shorten the course, reduce recurrent rate of HSK and have confirmed safety.
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Affiliation(s)
| | | | | | | | - Jianjiang Xu
- Department of Ophthalmology, EYE and ENT Hospital of Fudan University, Shanghai 200031, China
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Cholkar K, Trinh HM, Vadlapudi AD, Mitra AK. Synthesis and Characterization of Ganciclovir Long Chain Lipid Prodrugs. ACTA ACUST UNITED AC 2014; 1. [PMID: 25364778 DOI: 10.15406/aovs.2014.01.00007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Ganciclovir (GCV) is indicated for the treatment of human cytomegalo virus (HCMV) retinitis in immunocompromised patients. Sub-optimal physicochemical properties prevent GCV from reaching therapeutic concentrations in back of the eye (retina) tissue after oral and intravenous administration. Chronic high dose administration results in systemic toxicity. Local intravitreal injections suffer from poor ocular bioavailability and require repeated administration which can cause retinal detachment, retinal/vitreal hemorrhage and endophthalmitis. In the current study, we synthesized long chain acyl ester derivatives of GCV to improve lipophilicity and bioavailability. Ester conjugates (C5, C10 and C13 mono- and di-(O-acyl)) of GCV were synthesized in one step reaction following conventional esterification reaction. Purity of the novel prodrugs was determined with reversed phase high performance liquid chromatography. Conjugation of long lipid chain to GCV was confirmed with proton (1H) and carbon (13C) nuclear magnetic resonance and mass spectroscopy. Also, melting point and lipophilicity for the prodrugs and GCV were determined. MTS assay was used to assess in vitro toxicity of GCV and its long chain lipid prodrugs on human retinal pigment epithelial cell line (ARPE-19) cells. Results indicated that long chain lipid GCV prodrugs are nontoxic, safe and well-tolerated by ARPE-19 cells. These results suggest that novel long chain lipid GCV prodrugs may be further evaluated for ocular delivery and treatment of HCMV retinitis.
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Tashakori-Sabzevar F, Mohajeri SA. Development of ocular drug delivery systems using molecularly imprinted soft contact lenses. Drug Dev Ind Pharm 2014; 41:703-13. [DOI: 10.3109/03639045.2014.948451] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Agarwal A, Kumari N, Trehan A, Khadwal A, Dogra MR, Gupta V, Sharma A, Gupta A, Singh R. Outcome of cytomegalovirus retinitis in immunocompromised patients without Human Immunodeficiency Virus treated with intravitreal ganciclovir injection. Graefes Arch Clin Exp Ophthalmol 2014; 252:1393-401. [PMID: 24557658 DOI: 10.1007/s00417-014-2587-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 01/24/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022] Open
Abstract
PURPOSE To study the outcomes of treatment with intravitreal ganciclovir injection for cytomegalovirus (CMV) retinitis in patients without Human Immunodeficiency Virus (HIV) infection. METHODS In this retrospective cohort study, demographic and clinical characteristics of patients with CMV retinitis without HIV were noted. Patients received intravitreal ganciclovir injection (2 mg/0.1 ml) alone until quiescence. The outcome measures were time taken for the lesions to heal, number of injections, change in best-corrected visual acuity (BCVA), recurrence of retinitis, occurrence of immune recovery uveitis (IRU) or injection-related complications and retinal detachment (RD). RESULTS 18 eyes of ten patients (six males) with mean age of 33.7 years from June 2004 to March 2013 were included. Thirteen eyes with active lesions (mean BCVA of 0.51 ± 0.41) received 5.54 ± 3.36 intravitreal ganciclovir injections with complete healing within 1.81 ± 1.25 months. The final BCVA was 0.43 ± 0.52. IRU was observed in six eyes (33.33%) and RD developed in one eye. One eye had recurrence 1 month after stopping ganciclovir injections. The rest of the patients had recurrence-free follow-up at 9.46 ± 12.42 months. CONCLUSIONS Non-HIV patients with CMV retinitis can be successfully treated with intravitreal ganciclovir injection alone, avoiding the systemic side effects of systemic anti-CMV therapy.
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Affiliation(s)
- Aniruddha Agarwal
- Department of Ophthalmology, Advanced Eye Centre, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, 160012
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Hróbjartsson A, Thomsen ASS, Emanuelsson F, Tendal B, Rasmussen JV, Hilden J, Boutron I, Ravaud P, Brorson S. Observer bias in randomized clinical trials with time-to-event outcomes: systematic review of trials with both blinded and non-blinded outcome assessors. Int J Epidemiol 2014; 43:937-48. [PMID: 24448109 DOI: 10.1093/ije/dyt270] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND We wanted to evaluate the impact of nonblinded outcome assessors on estimated treatment effects in time-to-event trials. METHODS Systematic review of randomized clinical trials with both blinded and nonblinded assessors of the same time-to-event outcome. Two authors agreed on inclusion of trials and outcomes. We compared hazard ratios based on nonblinded and blinded assessments. A ratio of hazard ratios (RHR)<1 indicated that nonblinded assessors generated more optimistic effect estimates. We pooled RHRs with inverse variance random-effects meta-analysis. RESULTS We included 18 trials. Eleven trials (1969 patients) with subjective outcomes provided hazard ratios, RHR 0.88 (0.69 to 1.12), (I2=44%, P=0.06), but unconditional pooling was problematic because of qualitative heterogeneity. Four atypical cytomegalovirus retinitis trials compared experimental oral administration with control intravenous administration of the same drug, resulting in bias favouring the control intervention, RHR 1.33 (0.98 to 1.82). Seven trials of cytomegalovirus retinitis, tibial fracture and multiple sclerosis compared experimental interventions with standard control interventions, e.g. placebo, no-treatment or active control, resulting in bias favouring the experimental intervention, RHR 0.73 (0.57 to 0.93), indicating an average exaggeration of nonblinded hazard ratios by 27% (7% to 43%). CONCLUSIONS Lack of blinded outcome assessors in randomized trials with subjective time-to-event outcomes causes high risk of observer bias. Nonblinded outcome assessors typically favour the experimental intervention, exaggerating the hazard ratio by an average of approximately 27%; but in special situations, nonblinded outcome assessors favour control interventions, inducing a comparable degree of observer bias in the reversed direction.
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Affiliation(s)
- Asbjørn Hróbjartsson
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Ann Sofia Skou Thomsen
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Frida Emanuelsson
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Britta Tendal
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Jeppe Vejlgaard Rasmussen
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Jørgen Hilden
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Isabelle Boutron
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Philippe Ravaud
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
| | - Stig Brorson
- Nordic Cochrane Centre, Rigshospitalet Department 7811, Copenhagen, Denmark, Department of Orthopaedic Surgery, Herlev University Hospital, Copenhagen, Denmark, Department of Biostatistics, University of Copenhagen, Copenhagen, Denmark and French Cochrane Centre, Assistance Publique (Hotel Dieu), Université Paris Descartes, Paris, France
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Eid AJ, Razonable RR. Valganciclovir for the treatment of cytomegalovirus retinitis in patients with AIDS. EXPERT REVIEW OF OPHTHALMOLOGY 2014. [DOI: 10.1586/17469899.2.3.351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient's immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas.
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Affiliation(s)
- Michael W Stewart
- Department of Ophthalmology, Mayo School of Medicine, Jacksonville, FL, USA.
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18
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Janoly-Dumenil A, Rouvet I, Bleyzac N, Bertrand Y, Aulagner G, Zabot MT. Effect of duration and intensity of ganciclovir exposure on lymphoblastoid cell toxicity. Antivir Chem Chemother 2010; 19:257-62. [PMID: 19641234 DOI: 10.1177/095632020901900605] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Human cytomegalovirus infection is still a major complication after pediatric bone marrow transplantation and could be fatal in some cases. The toxicity of the drug in dividing transplanted haematopoietic cells combined with the suppression of cell growth caused by the virus remains a major problem in managing human cytomegalovirus infection. METHODS The aim of the current in vitro study was to evaluate the effect of the intensity (1-20 mg/l) and duration (1, 2, 7 or 14 days) of ganciclovir exposure on toxicity in B lymphoblastoid cells (using cell counting and viability measurements). RESULTS A correlation was found between the dose of ganciclovir exposure and a decrease in total cell number when duration exceeded 2 days (r(2)=0.92 and 0.93 after 7 and 14 days, respectively). High levels (20 mg/l) of ganciclovir were not more toxic than lowest levels (1 mg/l) for the shortest durations of ganciclovir exposure (1 and 2 days). Moreover, 50% cytotoxic concentrations markedly decreased with the duration of ganciclovir exposure (374-3 mg/l from 1 to 14 days respectively) after 14 days of culture. CONCLUSIONS This in vitro study demonstrated for the first time that ganciclovir exhibited an in vitro duration-dependent toxicity on haematopoietic-derived cells when in vivo doses of the drug were used.
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Perrottet N, Decosterd LA, Meylan P, Pascual M, Biollaz J, Buclin T. Valganciclovir in Adult Solid Organ Transplant Recipients. Clin Pharmacokinet 2009; 48:399-418. [DOI: 10.2165/00003088-200948060-00006] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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20
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Luan FL, Chopra P, Park J, Norman S, Cibrik D, Ojo A. Efficacy of Valganciclovir in the Treatment of Cytomegalovirus Disease in Kidney and Pancreas Transplant Recipients. Transplant Proc 2006; 38:3673-5. [PMID: 17175363 DOI: 10.1016/j.transproceed.2006.10.105] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2006] [Indexed: 11/20/2022]
Abstract
Cytomegalovirus (CMV) disease is relatively common following solid organ transplant, particularly if a serologically negative recipient receives an organ from a serologically positive donor (D+/R-). Although valganciclovir is approved for the treatment of CMV retinitis in AIDS patients and is used for the prophylaxis against CMV infection in solid organ transplant patients, the current standard treatment for CMV disease in solid organ transplant recipients remains intravenous ganciclovir. We retrospectively reviewed our experience using valganciclovir as treatment for CMV disease in CMV D+/R- kidney and/or pancreas transplant recipients from March 2002 to June 2005. A total of 37 cases with primary CMV disease were diagnosed and treated with either intravenous ganciclovir as induction followed with valganciclovir or valganciclovir from the beginning. We compared clinical outcomes and viremia between the two groups. Our data suggest that valganciclovir is an effective treatment modality for primary CMV disease in kidney and/or pancreas transplant recipients. It led to the resolution of disease and undetectable viremia. Valganciclovir allowed for early initiation of treatment and for treatment to be given as an outpatient. These advantages of valganciclovir have both health and economic impact for patients with CMV disease.
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Affiliation(s)
- F L Luan
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan 48109, USA.
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Affiliation(s)
- Torsten W Wiegand
- Massachusetts Eye and Ear Infirmary, 243 Charles Street, Boston, MA 02114, USA
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Abstract
Over the past several years, there has been an increase in knowledge pertaining to the diagnosis and management strategies for the herpes family (Types 1-8), the pox viruses, mumps, measles, rubella, and parvovirus B19 as well as the viral etiologies of hepatitis. Various antiviral treatments, such as nucleoside analogs and interferon therapy, have been available to reduce the signs and symptoms of these common viral infections. This article summarizes the preferred treatment strategies to be employed for each of the viruses for reducing severity, duration, recurrences (notably in the herpes family), transmission rates, as well as preventive alternatives. The majority of the therapeutic options attenuate the course of disease. Treatment decisions are driven by knowledge of the natural history and often are tailored to incorporate clinical circumstances for individual patients. Promotion of community awareness and the development of vaccines should be emphasized in the battle against these common viruses, particularly the herpes simplex viruses, the pox viruses, and hepatitis B.
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MESH Headings
- Animals
- Antiviral Agents/therapeutic use
- Diagnosis, Differential
- Hepatitis, Viral, Human/diagnosis
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/prevention & control
- Herpesviridae Infections/diagnosis
- Herpesviridae Infections/drug therapy
- Herpesviridae Infections/prevention & control
- Humans
- Measles/diagnosis
- Measles/drug therapy
- Measles/prevention & control
- Mumps/diagnosis
- Mumps/drug therapy
- Mumps/prevention & control
- Parvoviridae Infections/diagnosis
- Parvoviridae Infections/drug therapy
- Parvoviridae Infections/prevention & control
- Poxviridae Infections/diagnosis
- Poxviridae Infections/drug therapy
- Poxviridae Infections/prevention & control
- Rubella/diagnosis
- Rubella/drug therapy
- Rubella/prevention & control
- Skin Diseases, Viral/diagnosis
- Skin Diseases, Viral/drug therapy
- Skin Diseases, Viral/prevention & control
- Vaccination
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Abstract
Congenital infection caused by human cytomegalovirus (CMV) is a common occurrence, but its significance is underappreciated. In the developed world, congenital CMV infection confers a tremendous medical and economic burden on society. In recent years, appreciation of the scope of disability produced by such infections in newborns, which includes neurodevelopmental sequelae and sensorineural hearing loss (SNHL), has increased. Although much of the injury produced by infection in utero likely is irreversible, antiviral therapy of newborns with CMV infection is an option available to clinicians. Currently three antivirals are licensed for treatment of CMV: ganciclovir (and its prodrug, valganciclovir), foscarnet, and cidofovir. Novel antiviral therapies, which employ mechanisms of action that differ from these agents, also are in development. Experience with these agents in the setting of congenital and perinatal CMV infection is limited, but encouraging data come from a controlled clinical trial indicating that ganciclovir therapy may be of value in limiting the neurodevelopmental injury, particularly SNHL, caused by congenital infection. Newborn screening programs for CMV infection need to be developed and implemented. Infants with congenital CMV infection, once identified, could then be considered as candidates for antiviral therapy, and careful neurodevelopmental and hearing screening follow-up care plans could be established. CMV vaccines, once available, may ultimately be the best control strategy for this important public health problem.
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Affiliation(s)
- Mark R Schleiss
- Division of Pediatric Infectious Diseases and Immunology, University of Minnesota School of Medicine, Minneapolis, MN 55455, USA.
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Wang TJ, Lin CP, Yang CM, Lin LLK. Valgancyclovir as maintenance therapy for cytomegalovirus retinitis in a lung transplant patient—a case report. Transplant Proc 2004; 36:2826-9. [PMID: 15621160 DOI: 10.1016/j.transproceed.2004.09.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
UNLABELLED The purpose of this article is to report the use of valgancyclovir as maintenance therapy for cytomegalovirus (CMV) retinitis in a lung transplanted patient. RESULT A 30-year-old woman with underlying pulmonary lymphangioleiomyomatosis received a lung transplant 1 year ago. CMV retinitis developed 4 months later but subsided after intravenous ganciclovir treatment. Unfortunately, the CMV retinitis recurred three times in 1 year while on oral ganciclovir maintenance therapy. To treat the latest relapse, valgancyclovir 900 mg once daily was used as maintenance therapy after intravenous gancyclovir induction. With a 6-month follow-up, the fundoscopic examination revealed old atrophic scar and no active CMV retinits. The patient was able to maintain best-corrected visual acuity of 20/20 in both eyes. In conclusion, Valganciclovir may be used as maintenance therapy in CMV retinitis.
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Affiliation(s)
- T-J Wang
- Department of Ophthalmology, National Taiwan University Hospital, Taipei, Taiwan
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Abstract
The ocular posterior segment manifestations of AIDS may be divided into four categories: retinal vasculopathy, unusual malignancies, neuro-ophthalmologic abnormalities, and opportunistic infections. Microvasculopathy is the most common manifestation. Opportunistic infections, particularly cytomegalovirus retinitis and progressive outer retinal necrosis, are the most likely to result in visual loss due to infection or subsequent retinal detachment. Diagnosis and treatment are guided by the particular conditions and immune status of the patient.
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Affiliation(s)
- Tamara R Vrabec
- Wills Eye Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
Retinal drug delivery is a challenging area in the field of ophthalmic drug delivery. An ideal drug delivery system for the retina and vitreous humor has not yet been found, despite extensive research. Drug delivery to retinal tissue and vitreous via systemic administration is constrained due to the presence of a blood-retinal barrier (BRB) which regulates permeation of substances from blood to the retina. Although intravitreal administration overcomes this barrier, it is associated with several other problems. In recent years, transporter targeted drug delivery has become a clinically significant drug delivery approach for enhancing the bioavailabilities of drug molecules with poor membrane permeability characteristics. Various nutrient transporters, which include peptide, amino acid, folate, monocarboxylic acid transporters and so on, have been reported to be expressed on the retina and BRB. Prodrug derivatisation of drug molecules which target these transporters could result in enhanced ocular bioavailability. Highlighted in this review are various strategies currently employed for drug delivery to the posterior chamber, and novel opportunities that can be exploited to enhance ocular bioavailability of drugs.
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Affiliation(s)
- Sridhar Duvvuri
- Division of Pharmaceutical Sciences, School of Pharmacy, University of Missouri-Kansas City, 5005 Rockhill Road, Kansas City, MO 64110, USA
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Lalezari J, Lindley J, Walmsley S, Kuppermann B, Fisher M, Friedberg D, Lalonde R, Matheron S, Nieto L, Torriani FJ, Van Syoc R, Sutton MA, Buhles W, Stempien MJ. A safety study of oral valganciclovir maintenance treatment of cytomegalovirus retinitis. J Acquir Immune Defic Syndr 2002; 30:392-400. [PMID: 12138345 DOI: 10.1097/00042560-200208010-00004] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Valganciclovir, an oral prodrug of the anti-cytomegalovirus (CMV) agent ganciclovir, was evaluated in a single-arm open-label safety study. AIDS patients (median CD4 lymphocyte count of 140 cells/microL) with treated CMV retinitis (N = 212) received 900-mg once-daily valganciclovir maintenance therapy with courses of 900-mg twice-daily valganciclovir induction therapy as needed to treat progression. After a median treatment duration of 372 days, the adverse event profile was similar to that reported for intravenous (IV) and oral ganciclovir. Adverse event rates of note were diarrhea (35%), nausea (23%), fever (18%), neutropenia (absolute neutrophil count <500 cells/microL) (10%), and anemia (hemoglobin <8.0 g/dL) (12%). Consistent with prior treatment studies of oral ganciclovir, IV catheter-related adverse events were uncommon (6%) and lower than previously reported for IV ganciclovir. The mortality rate was 0.072 deaths per patient-year. Progression of CMV retinitis occurred in 17% of patients during the study treatment period, usually in association with a low CD4 cell count. Other than a higher than expected frequency of oral candidiasis (17%), no clinical toxicities or laboratory abnormalities occurred during treatment with valganciclovir that have not been observed during treatment with ganciclovir.
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Affiliation(s)
- Jacob Lalezari
- Quest Clinical Research, San Francisco, California 94115, USA.
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Martin DF, Sierra-Madero J, Walmsley S, Wolitz RA, Macey K, Georgiou P, Robinson CA, Stempien MJ. A controlled trial of valganciclovir as induction therapy for cytomegalovirus retinitis. N Engl J Med 2002; 346:1119-26. [PMID: 11948271 DOI: 10.1056/nejmoa011759] [Citation(s) in RCA: 295] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Valganciclovir is an orally administered prodrug that is rapidly hydrolyzed to ganciclovir. We compared the effects of oral valganciclovir with those of intravenous ganciclovir as induction therapy for newly diagnosed cytomegalovirus retinitis in 160 patients with the acquired immunodeficiency syndrome (AIDS). METHODS The primary end point was photographically determined progression of cytomegalovirus retinitis within four weeks after the initiation of treatment. Secondary end points included the achievement of a prospectively defined satisfactory response to induction therapy and the time to progression of cytomegalovirus retinitis. After four weeks, all patients received valganciclovir as maintenance therapy. RESULTS Eighty patients were randomly assigned to each treatment group. Of the patients who could be evaluated, 7 of 70 assigned to intravenous ganciclovir (10.0 percent) and 7 of 71 assigned to oral valganciclovir (9.9 percent) had progression of cytomegalovirus retinitis during the first four weeks (difference in proportions, 0.1 percentage point; 95 percent confidence interval, -9.7 to 10.0). Forty-seven of 61 patients (77.0 percent) assigned to intravenous ganciclovir and 46 of 64 (71.9 percent) assigned to valganciclovir had a satisfactory response to induction therapy (difference in proportions, 5.2 percentage points; 95 percent confidence interval, -20.4 to 10.1). The median times to progression of retinitis were 125 days in the group assigned to intravenous ganciclovir and 160 days in the group assigned to oral valganciclovir. The mean values for the area under the curve for the ganciclovir dosage interval were similar at both induction doses and maintenance doses. The frequency and severity of adverse events were similar in the two treatment groups. CONCLUSIONS Orally administered valganciclovir appears to be as effective as intravenous ganciclovir for induction treatment and is convenient and effective for the long-term management of cytomegalovirus retinitis in patients with AIDS.
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Affiliation(s)
- Daniel F Martin
- Department of Ophthalmology, Emory University School of Medicine, Atlanta, GA 30322, USA.
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