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van Vugt LK, Hesselink DA, de Winter BCM. Challenges for the improvement of valganciclovir prophylaxis in solid organ transplantation and the possible role of therapeutic drug monitoring in adults. Br J Clin Pharmacol 2024. [PMID: 38889884 DOI: 10.1111/bcp.16138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 06/20/2024] Open
Abstract
Cytomegalovirus (CMV) infection frequently occurs after solid organ transplantation and is associated with an increased morbidity and mortality. Fortunately, the development of valganciclovir prophylaxis has lowered the incidence of CMV infection and its complications in immunosuppressed solid organ transplant recipients. However, breakthrough infections during valganciclovir prophylaxis and late CMV infection after cessation of valganciclovir prophylaxis still occur with the current prophylactic strategy. Additionally, valganciclovir resistance has emerged among CMV strains, which complicates the treatment of CMV infections. Furthermore, the use of valganciclovir is associated with myelotoxicity, which can lead to the premature withdrawal of prophylaxis. It is important to address these current issues in order to improve the standard care after solid organ transplantation. This paper will therefore discuss the clinical practice of valganciclovir prophylaxis, elaborate on its issues and suggest how to improve the current prophylactic strategy with a possible role for therapeutic drug monitoring.
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Affiliation(s)
- Lukas K van Vugt
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Dennis A Hesselink
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Internal Medicine, Division of Nephrology and Transplantation, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
| | - Brenda C M de Winter
- Erasmus MC Transplant Institute, Rotterdam, the Netherlands
- Department of Hospital Pharmacy, Erasmus MC, University Medical Centre Rotterdam, the Netherlands
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Katada Y, Umemura K, Nakagawa S, Katsube Y, Tsuda M, Tanaka S, Date H, Nagao M, Terada T. A case of successful contribution of therapeutic drug monitoring of valganciclovir as the prophylaxis against cytomegalovirus infection in a lung transplant recipient. J Pharm Health Care Sci 2024; 10:28. [PMID: 38849960 PMCID: PMC11157855 DOI: 10.1186/s40780-024-00352-y] [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: 02/21/2024] [Accepted: 06/04/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Ganciclovir and its prodrug, valganciclovir, are first-line agents for cytomegalovirus infection prophylaxis after lung transplantation. Although valganciclovir prophylaxis is known to result in severe leukopenia as an adverse effect, dosage adjustment based on therapeutic drug monitoring (TDM) of ganciclovir concentration is not generally implemented in clinical practice. CASE PRESENTATION In this report, we describe the case of a female in her fifties after lung transplantation who successfully maintained valganciclovir prophylaxis under TDM with a minimal occurrence of severe leukopenia. Valganciclovir administration was initiated at a conventional dose of 450 mg/day on postoperative day 43 but was reduced to 450 mg/2 days on postoperative day 69 because of a decrease in white blood cell count and an increase in trough ganciclovir concentration. Subsequently, the valganciclovir dose adjustment was switched from label-indicated renal function-guided dosing to TDM-based dosing, targeting a trough level of 300-800 ng/mL. This target range was determined through deliberations with infectious disease specialists and pharmacists based on previously reported data. The TDM-based dose adjustment successfully prevented cytomegalovirus reactivation without causing significant adverse effects. Valganciclovir prophylaxis was completed on postoperative day 256, and the patient was transferred to another hospital for rehabilitation. CONCLUSIONS The findings of the present case suggest that TDM-based dosing could be helpful for clinicians in optimizing the prophylactic administration of valganciclovir in patients undergoing lung transplantation.
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Affiliation(s)
- Yoshiki Katada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
- Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan.
| | - Keisuke Umemura
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Shunsaku Nakagawa
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Yurie Katsube
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Masahiro Tsuda
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Graduate School of Pharmaceutical Sciences, Kyoto University, 46-29 Yoshida-Shimo-Adachi-Cho, Sakyo-Ku, Kyoto, 606-8501, Japan
| | - Satona Tanaka
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Miki Nagao
- Department of Infection Control and Prevention, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
- Department of Clinical Laboratory Medicine, Graduate School of Medicine, Kyoto University, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
| | - Tomohiro Terada
- Department of Clinical Pharmacology and Therapeutics, Kyoto University Hospital, 54 Shogoin- Kawahara-Cho, Sakyo-Ku, Kyoto, 606-8507, Japan
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Hardinger KL, Brennan DC. Cytomegalovirus Treatment in Solid Organ Transplantation: An Update on Current Approaches. Ann Pharmacother 2024:10600280241237534. [PMID: 38501850 DOI: 10.1177/10600280241237534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
OBJECTIVE The article reviews the safety and efficacy of treatments for cytomegalovirus (CMV) in solid organ transplantation. DATA SOURCES A literature review was conducted in PubMed, MEDLINE, and Clinicaltrials.gov from database inception through January 2024, using terms CMV, therapy, and solid organ transplantation. STUDY SELECTION AND DATA EXTRACTION Clinical trials, meta-analyses, cohort studies, case reports, and guidelines were included. Letters to the editor, reviews, and commentaries were excluded. DATA SYNTHESIS After abstract screening and full-text review of 728 citations for eligibility, 53 were included. Valganciclovir and intravenous ganciclovir are drugs of choice for CMV management and, until recently, the availability of alternative options has been restricted due to toxicity. For instance, foscarnet and cidofovir serve as second-line agents due to potential bone marrow and renal toxicity. In patients with refractory or resistant CMV, maribavir, a novel oral agent, has proven efficacy and a lower adverse effect profile. However, in refractory or resistant CMV, foscarnet and cidofovir are preferred in invasive disease (CMV gastritis, CMV retinitis, and CMV encephalitis), high viral loads, and inability to tolerate oral preparations. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE Consensus guidelines have not been revised since approval of novel antivirals in solid organ transplantation. Valganciclovir and ganciclovir remain drugs of choice for initial CMV therapy. Foscarnet, cidofovir, and maribavir are treatments for refractory or resistant-CMV. CONCLUSIONS Selection of CMV antiviral treatment should be determined by patient-specific factors, including severity of illness, resistant or refractory disease, dose-limiting adverse effects, and the preferred route of administration.
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Affiliation(s)
- Karen L Hardinger
- Division of Pharmacy Practice and Administration, School of Pharmacy, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Daniel C Brennan
- Johns Hopkins Comprehensive Transplant Center, Baltimore, MD, USA
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Xu J, Fang L, Chen J, Chen X, Yang H, Zhang W, Wu L, Chen D. Real-life effects, complications, and outcomes in 39 critically ill neonates receiving continuous kidney replacement therapy. Pediatr Nephrol 2023; 38:3145-3152. [PMID: 36988692 DOI: 10.1007/s00467-023-05944-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Continuous kidney replacement therapy (CKRT) has been expanded from simple kidney replacement therapy to the field of critical illness in children. However, CKRT is rarely used in critically ill neonates in the neonatal intensive care unit (NICU). This study aimed to describe patients' clinical characteristics at admission and CKRT initiation, CKRT effects, short-term outcomes, and predictors of death in critically ill neonates. METHODS A 7-year single-center retrospective study in a tertiary NICU. RESULTS Thirty-nine critically ill neonates received CKRT between May 2015 and April 2022 with a mortality rate of 35.9%. The most common primary diagnosis was neonatal sepsis in 15 cases (38.5%). Continuous veno-venous hemodiafiltration and continuous veno-venous hemofiltration were applied in 43.6% and 56.4% of neonates, respectively. The duration of CKRT was 44 (18, 72) h. Thirty-one patients (79.5%) had complications due to CKRT-related adverse events, and the most common complication was thrombocytopenia. Approximately 12 h after the CKRT initiation, urine volume, mean arterial pressure, and pH were increased, and serum creatinine, blood urea nitrogen, and blood lactate were decreased. In the multivariate logistic regression analysis, neonatal critical illness score [odds ratio 0.886 (0.786 ~ 0.998), P = 0.046] was an independent risk factor for death in critically ill neonates who received CKRT. CONCLUSIONS CKRT can be an effective and feasible technique in critically ill neonates, but the overall mortality and CKRT-related complications are relatively high. Furthermore, the probability of death is greater among neonates with greater severity of illness at CKRT initiation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Jinglin Xu
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Lingyu Fang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Jiangbin Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Xinhua Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Hansong Yang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Weifeng Zhang
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Lianqiang Wu
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China
| | - Dongmei Chen
- Department of Neonatology, Fujian Province, Quanzhou Maternity and Children's Hospital, Fengze Street, No 700, Quanzhou, 362000, China.
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Ecabert D, Pham C, Pierce BJ, Musick WL, Nguyen DT, Graviss EA. Safety of Valganciclovir 450 mg 3 Times Weekly for Cytomegalovirus Prophylaxis in Solid Organ Transplant Recipients Requiring Hemodialysis. Open Forum Infect Dis 2021; 8:ofab436. [PMID: 34646907 PMCID: PMC8501296 DOI: 10.1093/ofid/ofab436] [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: 07/16/2021] [Accepted: 08/20/2021] [Indexed: 11/14/2022] Open
Abstract
Background Valganciclovir is the most commonly used antiviral for cytomegalovirus (CMV) prophylaxis in solid organ transplant recipients. However, there are limited clinical outcomes-supported data available to guide valganciclovir dosing in patients on hemodialysis (HD). This study aimed to assess the safety of our institution's current dosing strategy of valganciclovir 450 mg 3 times weekly post-HD. Methods This was a single-center retrospective review of all adult nonkidney transplant recipients between May 2016 and June 2018. Patients with end-stage renal disease requiring HD for >28 days posttransplant receiving valganciclovir 450 mg 3 times weekly post-HD were matched with non-HD patients receiving valganciclovir prophylaxis dosed per renal function. The primary endpoints were incidence of leukopenia, neutropenia, and thrombocytopenia while on valganciclovir prophylaxis. Results A total of 465 nonkidney transplants were performed during the study period, with 37 patients included in the HD group who were matched to 111 control patients in the non-HD group. Liver transplant recipients comprised 84% and 72% of each group, with none being CMV D+/R-. The rates of leukopenia (51.4% vs 51.4%, P = 1.00), severe neutropenia (absolute neutrophil count <500 cells/µL, 15.8% vs 14.0%, P = .85), and thrombocytopenia (24.3% vs 20.7%, P = .64) were similar in both HD and non-HD groups. There were no cases of CMV infection while on valganciclovir prophylaxis in either group. Conclusions Valganciclovir 450 mg 3 times weekly was found to have similar rates of leukopenia, neutropenia, thrombocytopenia, and CMV infection in comparison to valganciclovir dosed per renal function in non-HD transplant recipients.
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Affiliation(s)
- Danielle Ecabert
- Houston Methodist Hospital, Department of Pharmacy, Houston, Texas,USA
| | - Christine Pham
- Houston Methodist Hospital, Department of Pharmacy, Houston, Texas,USA
| | - Brett J Pierce
- Houston Methodist Hospital, Department of Pharmacy, Houston, Texas,USA
| | - William L Musick
- Houston Methodist Hospital, Department of Pharmacy, Houston, Texas,USA
| | - Duc T Nguyen
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas,USA
| | - Edward A Graviss
- Houston Methodist Hospital, Department of Pathology and Genomic Medicine, Houston, Texas,USA.,Houston Methodist Hospital, Department of Surgery, Houston, Texas,USA
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Franck B, Autmizguine J, Marquet P, Ovetchkine P, Woillard JB. Pharmacokinetics, Pharmacodynamics, and Therapeutic Drug Monitoring of Valganciclovir and Ganciclovir in Transplantation. Clin Pharmacol Ther 2021; 112:233-276. [PMID: 34596243 DOI: 10.1002/cpt.2431] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/20/2021] [Indexed: 01/17/2023]
Abstract
Ganciclovir and valganciclovir are first choice drugs for the prevention and treatment of cytomegalovirus infection and disease in solid organ and stem cell transplant recipients. Only a few studies on the pharmacokinetics and exposure/efficacy or exposure/safety relationships of ganciclovir and valganciclovir in transplant recipients have been published so far, and there are still controversies about the exposure parameter to use for therapeutic drug monitoring (TDM). We performed an extensive literature review of the clinical pharmacokinetics data, the exposure/effect relationships in terms of efficacy and safety, and the available tools for valganciclovir and ganciclovir TDM in adults and pediatrics transplant recipients. The pharmacokinetics of ganciclovir and valganciclovir is well described in adults and children, and a high interindividual variability is commonly observed. In contrast, the drug pharmacodynamics has been poorly described in adults and barely in children. The average 24-hour area under the concentration-time curve (AUC0-24h ) seems to be the best predictor of efficacy and toxicity. The benefit of TDM remains controversial in adult patients but should be considered in children due to higher interindividual variability and lower probability of target attainment. Several bayesian estimators based on limited sampling strategies have been developed with this aim and may be used in clinical practice for the AUC-based individual dose adjustment of ganciclovir and valganciclovir.
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Affiliation(s)
- Bénédicte Franck
- Individual Profiling and Prevention of Risks With Immunosuppressive Therapies and Transplantations, Unité Mixte de Recherche 1248 Université de Limoges, Institut National de la Santé et de la Recherche Médicale, Limoges, France.,Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Julie Autmizguine
- Research Center, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada.,Department of Pharmacology and Physiology, Université de Montréal, Montreal, Quebec, Canada
| | - Pierre Marquet
- Individual Profiling and Prevention of Risks With Immunosuppressive Therapies and Transplantations, Unité Mixte de Recherche 1248 Université de Limoges, Institut National de la Santé et de la Recherche Médicale, Limoges, France.,Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Philippe Ovetchkine
- Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, Canada
| | - Jean-Baptiste Woillard
- Individual Profiling and Prevention of Risks With Immunosuppressive Therapies and Transplantations, Unité Mixte de Recherche 1248 Université de Limoges, Institut National de la Santé et de la Recherche Médicale, Limoges, France.,Service de Pharmacologie, Toxicologie et Pharmacovigilance, Centre Hospitalier Universitaire de Limoges, Limoges, France
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