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Gublo B, St Amand AB, Menon A, Scalise AA. Valacyclovir Neurotoxicity in Patients with End-Stage Renal Disease: Two Cases Reviewed. J Pharm Pract 2024; 37:248-251. [PMID: 38247339 DOI: 10.1177/08971900221127061] [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] [Indexed: 01/23/2024]
Abstract
Purpose: The objective of this case series is to highlight different manifestations of valacyclovir associated neurotoxicity (VAN) and demonstrate the importance of adjusting medication appropriately in patients with end-stage renal disease (ESRD) on hemodialysis to prevent these complications. Summary: Valacyclovir is a medication used to treat herpes zoster infection, commonly known as shingles. Valacyclovir is renally cleared and can accumulate in patients with renal dysfunction leading to severe side effects due to the prolonged half-life. VAN is a common adverse effect in patients with underlying kidney disease, that can be easily prevented if valacyclovir is properly dosed. This case series details the clinical outcomes of two elderly patients who were prescribed valacyclovir at six-times the recommended dose based on their renal function. Failure to reduce the dose of valacyclovir resulted in severe neurological and physical manifestations that required hospital admission and emergent hemodialysis. Conclusion: This case series details the importance of adjusting valacyclovir dose based on renal function. In patients with ESRD, the half-life of valacyclovir can be up to 14 hours, therefore hemodialysis should be utilized in severe cases of neurotoxicity to improve rapid excretion of the drug and promote rapid recovery from VAN.
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Affiliation(s)
- Bernadette Gublo
- Clinical Pharmacy, Providence Veteran Affairs Medical Center, Providence, RI, USA
| | - Amy Beth St Amand
- Clinical Pharmacy, Providence Veteran Affairs Medical Center, Providence, RI, USA
| | - Anupama Menon
- Clinical Pharmacy, Providence Veteran Affairs Medical Center, Providence, RI, USA
| | - Alissa A Scalise
- Clinical Pharmacy, Providence Veteran Affairs Medical Center, Providence, RI, USA
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Lee H, Martin SO, Lee M, Munjal S. Valacyclovir-Associated Catatonia: A Case Highlighting Its Neuropsychiatric Adverse Effects. J Clin Psychopharmacol 2023; 43:469-471. [PMID: 37683243 DOI: 10.1097/jcp.0000000000001741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Affiliation(s)
- HoLim Lee
- Department of Psychiatry and Behavioral Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC
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Egloff C, Sibiude J, Vauloup-Fellous C, Benachi A, Bouthry E, Biquard F, Hawkins-Villarreal A, Houhou-Fidouh N, Mandelbrot L, Vivanti AJ, Picone O. New data on efficacy of valacyclovir in secondary prevention of maternal-fetal transmission of cytomegalovirus. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:59-66. [PMID: 35900718 DOI: 10.1002/uog.26039] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/21/2022] [Accepted: 07/18/2022] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Congenital cytomegalovirus (CMV) infection is the leading cause of non-genetic hearing and neurological deficits. The aim of our study was to evaluate the efficacy and safety of valacyclovir (VCV) treatment in preventing CMV transmission to the fetus after maternal primary infection. METHODS This was a retrospective, multicenter study evaluating the rate of maternal-fetal CMV transmission in pregnancies with maternal primary CMV infection treated with VCV at a dosage of 8 g per day (VCV group) compared with a control group of untreated women. Each case underwent virological testing to confirm maternal primary infection and to provide accurate dating of onset of infection. The primary outcome was the presence of congenital CMV infection at birth diagnosed based on polymerase chain reaction analysis of saliva, urine and/or blood samples. The efficacy of VCV treatment was assessed using logistic regression analysis adjusted for a propensity score. RESULTS In total, 143 patients were included in the final analysis, of whom 59 were in the VCV group and 84 were in the untreated control group. On propensity-score-adjusted analysis, VCV treatment was significantly associated with an overall reduction in the rate of maternal-fetal CMV transmission (odds ratio, 0.40 (95% CI, 0.18-0.90); P = 0.029). The rate of maternal-fetal CMV transmission, determined at birth, in the VCV vs control group was 7% (1/14) vs 10% (1/10) after periconceptional maternal primary infection (P = 1.00), 22% (8/36) vs 41% (19/46) after first-trimester maternal primary infection (P = 0.068) and 25% (2/8) vs 52% (14/27) after second-trimester maternal primary infection (P = 0.244). When analyzing the efficacy of VCV treatment according to maternal viremia at treatment initiation, there was a trend towards greater efficacy when patients were viremia-positive (21% vs 43%; P = 0.072) compared with when they were viremia-negative (22% vs 17%; P = 0.659). Maternal side effects associated with VCV were mild and non-specific in most cases. CONCLUSION Our findings indicate that VCV treatment of pregnant women with primary CMV infection reduces the risk of maternal-fetal transmission of CMV and may be effective in cases with primary infection in the first and second trimesters. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- C Egloff
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
| | - J Sibiude
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
| | - C Vauloup-Fellous
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Virology Department, Hôpital Paul-Brousse, INSERM U1993, Université Paris Saclay, AP-HP, Villejuif, France
| | - A Benachi
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Obstetrics and Gynecology, DMU Santé des Femmes et des Nouveau-nés, Hôpital Antoine Béclère, Paris Saclay University, AP-HP, Clamart, France
| | - E Bouthry
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Biology of Infectious Agents, Angers University Hospital, Angers, France
| | - F Biquard
- Department of Obstetrics and Gynaecology, Angers University Hospital, Angers, France
| | - A Hawkins-Villarreal
- BCNatal Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Fetal Medicine Service, Obstetrics Department, Santo Tomás Hospital, University of Panama, Panama City, Panama (on behalf of the Iberoamerican Research Network in Obstetrics, Gynecology and Translational Medicine)
| | - N Houhou-Fidouh
- Virology Department, Hôpital Bichat Claude-Bernard, Université de Paris, AP-HP, Paris, France
| | - L Mandelbrot
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
| | - A J Vivanti
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
- Department of Obstetrics and Gynecology, DMU Santé des Femmes et des Nouveau-nés, Hôpital Antoine Béclère, Paris Saclay University, AP-HP, Clamart, France
| | - O Picone
- Service de Gynécologie-Obstétrique, Hôpital Louis-Mourier, AP-HP, Colombes, France
- University of Paris, Paris, France
- IAME, INSERM, Paris, France
- FHU PREMA, Paris, France
- Research Group on Infections during Pregnancy (GRIG), Velizy, France
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Wang YC, Juan SH, Li CH, Chou CL, Chen LY, Chien LN, Fang TC. Valacyclovir-associated neurotoxicity among patients on hemodialysis and peritoneal dialysis: A nationwide population-based study. Front Med (Lausanne) 2022; 9:997379. [PMID: 36203771 PMCID: PMC9530346 DOI: 10.3389/fmed.2022.997379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Whether valacyclovir-associated neurotoxicity (VAN) occurs more frequently in patients with end-stage renal disease (ESRD) on dialysis is unknown. This is the first population-based study to examine the risk of VAN associated with ESRD patients on dialysis. Among 2,284,800 patients diagnosed as having herpes zoster from 2002 to 2016, patients with ESRD on dialysis and individuals with normal renal function were enrolled in this study. Following propensity score matching, we compared the risk of altered mental status between valacyclovir users and non-users in the ESRD and normal renal function cohorts over a 30-day follow-up period. In the ESRD cohort, the incidence of altered mental status was 1.68 and 0.52 per 1,000 person-day in valacyclovir users and non-users, respectively, with an adjusted hazard ratio (HR) of 3.22 (95% confidence interval [CI]: 2.04–4.99, P < 0.001). The incidence of altered mental status of valacyclovir users on hemodialysis (HD) and peritoneal dialysis (PD) was higher than that of non-users. The adjusted HR was 3.20 (95% CI: 1.98–5.15, P < 0.001) for those on HD and 3.44 (95% CI: 1.13–10.49, P = 0.030) for those with PD. However, altered mental status was not observed in patients on HD receiving ≤500 mg of valacyclovir three times per week or in those on PD receiving ≤500 mg of valacyclovir per day. The findings demonstrate that adjusting the valacyclovir dosage and monitoring VAN in patients with HD and PD who have herpes zoster is crucial.
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Affiliation(s)
- Yi-Chun Wang
- Division of Nephrology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei City, Taiwan
- School of Medicine, Tzu Chi University, Hualien, Taiwan
| | - Shu-Hui Juan
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Ching-Hao Li
- Department of Physiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chu-Lin Chou
- TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Hsin Kuo Min Hospital, Taipei Medical University, Taoyuan City, Taiwan
- Division of Nephrology, Department of Internal Medicine, Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Li-Ying Chen
- Health Data Analytics and Statistics Center, Office of Data Science, Taipei Medical University, Taipei, Taiwan
| | - Li-Nien Chien
- Institute of Health and Welfare Policy, College of Medicince, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Graduate Institute of Data Science, College of Management, Taipei Medical University, Taipei, Taiwan
- Li-Nien Chien,
| | - Te-Chao Fang
- TMU Research Center of Urology and Kidney, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei Medical University, Taipei, Taiwan
- *Correspondence: Te-Chao Fang,
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Tai T, Yamaguchi K, Kurokawa N, Shinmura W, Matsubara A, Watanabe M, Motoki T, Tanaka H, Houchi H, Kosaka S. [A Pharmacist's Query Avoiding Exacerbation of Adverse Effects in a Patient with Acyclovir Encephalopathy: A Case Report]. YAKUGAKU ZASSHI 2022; 142:771-774. [PMID: 35781507 DOI: 10.1248/yakushi.21-00237] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
We report a haemodialysis patient with end-stage renal failure whom a pharmacist aided in the management of acyclovir (ACV) encephalopathy, which may have been related to valacyclovir hydrochloride (VACV) administered without sufficient dose reduction. The patient 78 years was admitted with a tentative diagnosis of varicella zoster viral meningitis. A pharmacist suspected ACV encephalopathy related to excessive VACV administration and raised a query with the attending physician. According to the pharmacist's proposal, ACV administration was discontinued and continuous hemodiafiltration (CHDF) was performed. On day 5 of hospitalisation, the consciousness disorder was improved. In this report, we showed the detailed CHDF conditions of the present case, and the contribution of a pharmacist to treating and avoiding ACV encephalopathy was discussed.
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Affiliation(s)
- Tatsuya Tai
- Department of Pharmacy, Kagawa University Hospital
| | | | | | | | | | | | | | | | - Hitoshi Houchi
- Kagawa School of Pharmaceutical Sciences, Tokushima Bunri University
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Shan Y, Cen Y, Zhang Y, Tan R, Zhao J, Nie Z, Zhang J, Yu S. Acyclovir Brain Disposition: Interactions with P-gp, Bcrp, Mrp2, and Oat3 at the Blood-Brain Barrier. Eur J Drug Metab Pharmacokinet 2022; 47:279-289. [PMID: 35112329 DOI: 10.1007/s13318-021-00733-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/03/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND OBJECTIVE Acyclovir is effective in treating herpes simplex virus infections of the central nervous system. The purpose of this study was to investigate the interactions between acyclovir and the efflux pumps P-glycoprotein (P-gp), breast cancer resistance protein (Bcrp), multidrug resistance protein 2 (Mrp2), and organic anion transporter 3 (Oat3) at the blood-brain barrier (BBB). METHODS Acyclovir concentrations in the blood and brain were evaluated by microdialysis and high-performance liquid chromatography. Acyclovir pharmacokinetic parameters, including the area under the unbound blood concentration-time curve (AUCu,blood), the area under the unbound brain concentration-time curve (AUCu,brain), and the ratio of AUCu,brain to AUCu,blood (Kp.uu.brain), were evaluated in the presence and absence of elacridar (P-gp/Bcrp inhibitor, 7.5 mg/kg), tariquidar (P-gp/Bcrp inhibitor, 7.5 mg/kg), MK571 (Mrp2 inhibitor, 7.5 mg/kg), cyclosporine (P-gp/Bcrp/Mrp2 inhibitor, 25 mg/kg), and probenecid (Oat3 inhibitor, 50 mg/kg). RESULTS The average AUCu,blood, AUCu,brain, and Kp.uu.brain in rats who received acyclovir (25 mg/kg, intravenous) alone were 1377.7 min · μg/ml, 435.4 min · μg/ml, and 31.6%, respectively. Probenecid drastically increased the AUCu,blood of acyclovir 1.73-fold, whereas coadministration with elacridar, tariquidar, MK571, and cyclosporine did not alter the blood pharmacokinetic parameters of acyclovir. Elacridar, tariquidar, MK571, cyclosporine, and probenecid significantly increased the AUCu,brain of acyclovir 1.51-, 1.54-, 1.47-, 1.95-, and 2.34-fold, respectively. Additionally, the Kp.uu.brain of acyclovir markedly increased 1.48-, 1.63-, 1.39-, 1.90-, and 1.35-fold following elacridar, tariquidar, MK571, cyclosporine, and probenecid administration, respectively. CONCLUSION The present study demonstrated that P-gp, Bcrp, Mrp2, and Oat3 inhibition increased the penetration of acyclovir across the BBB, supporting the hypothesis that these efflux pumps restrict the distribution of acyclovir in the brain.
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Affiliation(s)
- Yuheng Shan
- Medical School of Chinese PLA, Beijing, 100853, People's Republic of China
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
- Department of Neurology, Characteristic Medical Centre of People's Armed Police Force, Tianjin, 300162, People's Republic of China
| | - Yuying Cen
- Medical School of Chinese PLA, Beijing, 100853, People's Republic of China
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Yanjin Zhang
- State Key Laboratory of Toxicology and Medical Countermeasures, Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences, Beijing, 100850, People's Republic of China
| | - Ruishu Tan
- Medical School of Chinese PLA, Beijing, 100853, People's Republic of China
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Jiahua Zhao
- Medical School of Chinese PLA, Beijing, 100853, People's Republic of China
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
| | - Zhiyong Nie
- State Key Laboratory of Toxicology and Medical Countermeasures, Institute of Pharmacology and Toxicology, Academy of Military Medical Sciences, Beijing, 100850, People's Republic of China.
| | - Jiatang Zhang
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China.
| | - Shengyuan Yu
- Department of Neurology, The First Medical Centre, Chinese PLA General Hospital, Beijing, 100853, People's Republic of China
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7
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Brandariz-Nuñez D, Correas-Sanahuja M, Maya-Gallego S, Martín Herranz I. Neurotoxicity associated with acyclovir and valacyclovir: A systematic review of cases. J Clin Pharm Ther 2021; 46:918-926. [PMID: 34146428 DOI: 10.1111/jcpt.13464] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 05/15/2021] [Accepted: 05/24/2021] [Indexed: 11/29/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Acyclovir and valacyclovir are commonly used antivirals with good general tolerance. Despite their good safety profile, they can cause systemic adverse effects, such as neurotoxicity, which are less frequent and known. The objective of this review was to collect all the reported cases of neurotoxicity associated with acyclovir and valaciclovir published in the literature and characterize their clinical course and interventions. METHODS A systematic review of cases was carried out following the guidelines established by "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA). The research was carried out using the PubMed-Medline and Embase databases, between July 1984 and March 2021. RESULTS AND DISCUSSION A total of 119 cases with neurotoxicity mainly related to acyclovir (n = 88; 73.9%), followed by valaciclovir (n = 35; 29.4%) were analysed. 49.6% (n = 59) were men with a mean age of 59.5 years ± 21.1 (0.5-88). In 83.3% of the cases, renal impairment was documented and 57.1% (n = 68) with end-stage renal disease. The administered dose was higher than the renal adjustment recommendations in 59.7% of the cases. The global mean of onset of symptoms was 3.1 days ± 4.3 (0.2-28) after the start of antivirals. The mean recovery time was 9.8 days ± 21.7 (0.2-180). 74.4% of the patients had a recovery of ≤7 days, 15.9% between 8 and 15 days and 9.8% > 15 days. WHAT IS NEW AND CONCLUSION The neurotoxicity induced by acyclovir and its derivative valacyclovir is a poorly known and rare adverse effect that can occur mainly in patients with advanced age and impaired renal function. The most characteristic symptoms are confusion, altered level of consciousness, hallucinations, agitation and dysarthria. The basis of treatment is the discontinuation of the antiviral, and in some cases, it may require additional clearance by dialysis.
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Affiliation(s)
| | | | - Sara Maya-Gallego
- Pediatric Infectious Disease Service, San Joan de Deu Hospital, Barcelona, Spain
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Tan MSH, Chung SJ, Ho QY, Thangaraju S, Kee TYS. A single-centre observational study comparing the impact of different cytomegalovirus prophylaxis strategies on cytomegalovirus infections in kidney transplant recipients. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/2010105820953461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background/objective: Prevention of cytomegalovirus (CMV) infection is an important component of post kidney transplant care. We aimed to evaluate the impact of two different CMV prophylaxis protocols on the epidemiology and outcomes of CMV infections at our centre. Methods: This is a single-centre retrospective before/after observational study. Kidney transplant recipients who received Protocol 1, a valacyclovir- or valganciclovir-based regimen prescribed for one to three months based on the CMV risk status between 2004 and 2008, were compared to those who received Protocol 2, a valganciclovir-based regimen prescribed for three months and six months for those at moderate and high risk, respectively, between 2010 and 2014. The impact of different prophylaxis regimens on the incidence of CMV infections, disease, recurrent infections and onset of CMV infection at 24 months were reviewed. Results: There were 192 patients included; 106 patients received Protocol 1, 86 received Protocol 2. At 24 months, the incidence of CMV infection was 53.8% and 55.8% in Protocols 1 and 2, respectively ( p=0.884). The incidence rates of CMV disease and recurrent CMV infections were higher in Protocol 1, but this was not statistically significant. The median time to first CMV infection was significantly shorter in patients who received Protocol 1: 132 days (interquartile range (IQR) 125–139 days) versus 185 days (IQR 178–192 days), p=0.001. Both prophylaxis protocols were well tolerated. Conclusion: The incidence of CMV infection was similar in both protocols. Where valganciclovir is not available, valacyclovir may be considered over no prophylaxis. Post-prophylaxis CMV infections are not uncommon, and vigilance for it should be advocated.
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Affiliation(s)
- Mabel Si Hua Tan
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Shimin Jasmine Chung
- Department of Infectious Disease, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | - Quan Yao Ho
- Department of Renal Medicine, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | - Sobhana Thangaraju
- Department of Renal Medicine, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
| | - Terence Yi Shern Kee
- Department of Renal Medicine, Singapore General Hospital, Singapore
- SingHealth Duke-NUS Transplant Centre, Singapore
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Kenzaka T, Sugimoto K, Goda K, Akita H. Acute kidney injury and acyclovir-associated encephalopathy after administration of valacyclovir in an elderly person with normal renal function: A case report and literature review. Medicine (Baltimore) 2021; 100:e26147. [PMID: 34032768 PMCID: PMC8154488 DOI: 10.1097/md.0000000000026147] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/11/2021] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION Acyclovir (ACV)-associated encephalopathy is related to an increase in plasma levels of 9-carboxymethoxymethylguanine, an ACV metabolite, and is often reported in patients with renal dysfunction. We report a case of ACV-associated encephalopathy with rapid progression of renal dysfunction after oral administration of valacyclovir (VACV) and review literature of previous ACV-associated encephalopathy cases. PATIENT CONCERNS An 88-year-old man was diagnosed with herpes zoster. VACV (3000 mg/day) treatment was initiated. Serum creatinine (Cr) level was 0.80 mg/dL. However, irritability, memory impairment, and decreased responsiveness occurred after 3 days. The Cr level was 6.76 mg/dL on admission. DIAGNOSIS He was diagnosed with ACV-associated encephalopathy with acute kidney injury. INTERVENTIONS VACV was discontinued, hemodialysis was initiated on the day of admission, and then the signs and symptoms improved approximately 72 hours after the admission. CONCLUSION Worsening of renal function and encephalopathy should be a focus when using VACV or ACV, regardless of age and original renal function. Acute kidney injury and ACV-associated encephalopathy may particularly occur in the elderly even when renal function is normal. Therefore, regular monitoring of renal function and consciousness is necessary during VACV treatment.
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Affiliation(s)
- Tsuneaki Kenzaka
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazuma Sugimoto
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
| | - Ken Goda
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
- Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hozuka Akita
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba
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10
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Memon W, Rose EK, Akram A, Simba B. A Unique Case of Valacyclovir Toxicity and Pseudobulbar Affect in a Patient On Peritoneal Dialysis. Cureus 2021; 13:e13494. [PMID: 33777579 PMCID: PMC7990347 DOI: 10.7759/cureus.13494] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
There are a few cases of valacyclovir-associated neurotoxicity (VAN) reported. This case report documents a case of a 55-year-old male presenting with emotional lability or pseudobulbar affect as the predominant or sole manifestation of VAN. A failure to adjust valacyclovir's dose for herpes simplex infection in the setting of dialysis-dependent end-stage renal disease (ESRD) preceded VAN in this patient. The patient presented with involuntary and uncontrollable outbursts of emotion. Computerized tomography (CT) scan identified no underlying cause. A complete neurological examination with cognitive assessment was performed, with no abnormalities. He benefited from the use of aggressive peritoneal dialysis (PD) that was employed to enhance valacyclovir's clearance in this case of intractable VAN. On discharge, the patient was back to baseline mental function. Traumatic brain injury, neoplasm, vascular lesions, metabolic abnormality, neurological disease, herpetic encephalitis, and disorders of mood were ruled out. This led to the hypothesis of encephalopathy due to valacyclovir intoxication. Given that the clinical manifestations were related to ESRD, a dose-adjustment of valacyclovir is imperative in the setting of ESRD to prevent VAN. Our case presents important clinical variations. Firstly, our patient demonstrates that VAN may present with no focal neurological impairment, but pseudobulbar affect. Secondly, aggressive PD was useful in this case for the treatment of VAN as opposed to hemodialysis. We believe that it cleared valacyclovir resulting in the resolution of symptoms.
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Affiliation(s)
- Waqas Memon
- Internal Medicine/Nephrology, Virginia Commonwealth University, Richmond, USA
| | - Emily K Rose
- Internal Medicine, Virginia Commonwealth University, Richmond, USA
| | - Ayesha Akram
- Internal Medicine, Combined Military Hospital, Rawalpindi, PAK.,Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK
| | - Brian Simba
- Internal Medicine/Nephrology, Virginia Commonwealth University, Richmond, USA
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Sugimoto K, Kenzaka T, Sugimoto R, Kitao A, Akita H. Encephalopathy Induced by Preventive Administration of Acyclovir in a Man with Symptomatic Multiple Myeloma and Renal Dysfunction. Int J Gen Med 2021; 14:413-417. [PMID: 33603447 PMCID: PMC7886295 DOI: 10.2147/ijgm.s291320] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/26/2021] [Indexed: 11/23/2022] Open
Abstract
Background Acyclovir (ACV) neurotoxicity is a neuropsychiatric condition induced by the anti-herpetic drugs ACV and valacyclovir (VACV). It is presumed that elevated blood levels of ACV and its metabolite 9-carboxymethoxymethylguanine are involved in the development of ACV-induced encephalopathy; age and renal dysfunction are risk factors. Here, we report a case of encephalopathy caused by the administration of VACV for herpes zoster prophylaxis in a patient with renal dysfunction owing to multiple myeloma. Case Presentation Renal dysfunction was diagnosed in a 70-year-old man visiting our hospital for a medical checkup. His creatinine clearance rate was 8 mL/min. He was diagnosed with symptomatic multiple myeloma, and bortezomib/dexamethasone (BD) therapy for multiple myeloma and VACV for herpes zoster prophylaxis were initiated. We administered 500 mg/day of VACV three times a week, a lower dosage than recommended, after adjusting for his renal impairment. His renal function was monitored twice per week during therapy. During the second course of BD therapy, 6 weeks after starting treatment, he was hospitalized owing to impaired consciousness (Glasgow Coma Scale score: E2, V4, M4), and his BD and VACV therapy were suspended. Brain magnetic resonance imaging and cerebrospinal fluid analysis showed no abnormalities. Three days after discontinuing BD and VACV therapy, his consciousness recovered completely, and impaired consciousness did not recur after resuming BD therapy. His clinical diagnosis was thus ACV-induced encephalopathy. Conclusion VACV is often prescribed to patients with multiple myeloma receiving BD therapy to prevent herpes zoster. ACV-induced encephalopathy is commonly observed in patients with renal dysfunction; especially among patients with multiple myeloma with Bence–Jones proteinuria, renal tubules are easily damaged and plasma ACV concentrations are likely to increase and induce ACV-induced encephalopathy. Careful monitoring of the level of consciousness is necessary during preventive ACV therapy in patients with renal dysfunction.
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Affiliation(s)
- Kazuma Sugimoto
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Hyogo, Japan
| | - Tsuneaki Kenzaka
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Hyogo, Japan.,Division of Community Medicine and Career Development, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Ryu Sugimoto
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Hyogo, Japan
| | - Akihito Kitao
- Division of Medical Oncology/Hematology, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan
| | - Hozuka Akita
- Department of Internal Medicine, Hyogo Prefectural Tamba Medical Center, Tamba, Hyogo, Japan
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12
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[Psychiatric aspects in treatment of HIV]. MMW Fortschr Med 2020; 162:34-37. [PMID: 32583251 DOI: 10.1007/s15006-020-0643-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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13
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14
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Marks D, De La Paz A, Walston BJ. Acyclovir-induced neurotoxicity in an immunocompromised patient. SAGE Open Med Case Rep 2020; 8:2050313X20946518. [PMID: 32850129 PMCID: PMC7425261 DOI: 10.1177/2050313x20946518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 07/13/2020] [Indexed: 11/25/2022] Open
Abstract
This is a case report of a 75-year-old immunocompromised male who developed encephalopathy while undergoing treatment for disseminated herpes zoster with peripheral nerve involvement. While his initial presentation involved primarily profound lower extremity weakness, he developed progressive confusion to the point of obtundation only after initiation of standard therapy with intravenous acyclovir. The evaluation of his altered mental status was largely unremarkable. It was only after his acyclovir was discontinued that his symptoms resolved and he returned to his baseline mental status. His presentation was most consistent with acyclovir-induced neurotoxicity, which can present in patients with renal impairment and those who are immunocompromised.
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Affiliation(s)
- Daniel Marks
- School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Andrew De La Paz
- Internal Medicine Residency Program, School of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Bobbi Jo Walston
- Infectious Diseases, Eshelman School of Pharmacy, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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Zareifopoulos N, Lagadinou M, Karela A, Kyriakopoulou O, Velissaris D. Neuropsychiatric Effects of Antiviral Drugs. Cureus 2020; 12:e9536. [PMID: 32905132 PMCID: PMC7465925 DOI: 10.7759/cureus.9536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The adverse events of antiviral drugs are dose-dependent and often reversible. The nervous system is often affected and to date, many studies have been published regarding the central nervous system toxicity of antiviral agents. They may cause significant neuropsychiatric complications, which range from mild symptoms such as irritability and difficulty sleeping to severe complications such as depression, psychosis, and painful peripheral neuropathy, side effects which may necessitate discontinuation of treatment. The pathogenetic mechanisms may involve molecular targets common to other centrally active drugs, including human monoamine oxidase‐A (MAO‐A), serotonin receptors, gamma-aminobutyric acid (GABA) GABA-A receptors, 5-HT2A and 5-HT2C receptors and others. Notable examples include oseltamivir which may act as MAO inhibitor and efavirenz, which has an affinity for serotonin 5-HT2 and GABA-A receptors, the serotonin transporter, the MAO enzyme, and the vesicular monoamine transporter, with subjective effects which may be similar to those of the psychedelic hallucinogen lysergic acid diethylamide (LSD). Other antiviral drugs with prominent nervous system effects include nucleoside reverse transcriptase inhibitors, which are associated with the development of peripheral neuropathy after prolonged use (an effect strongly associated with older drugs which have since fallen into disfavor such as stavudine) and interferons, which may cause depression. Clinicians should be familiar with such adverse effects in order to recognise them promptly once they occur and manage them appropriately.
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Affiliation(s)
| | - Maria Lagadinou
- Emergency Department, General University Hospital of Patras, Patras, GRC
| | - Anastasia Karela
- Emergency Department, General University Hospital of Patras, Patras, GRC
| | | | - Dimitrios Velissaris
- Department of Internal Medicine, University of Patras, School of Health Sciences, Patras, GRC.,Emergency Department, General University Hospital of Patras, Patras, GRC
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16
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Rosales-Castillo A, López-González Gila JDD, Clavero García E. [Neurotoxicity secondary to valacyclovir]. Med Clin (Barc) 2020; 156:361-362. [PMID: 32115197 DOI: 10.1016/j.medcli.2019.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/06/2019] [Accepted: 12/19/2019] [Indexed: 11/25/2022]
Affiliation(s)
| | | | - Elena Clavero García
- Servicio de Nefrología, Hospital Universitario Virgen de las Nieves, Granada, España
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17
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Devanand DP, Andrews H, Kreisl WC, Razlighi Q, Gershon A, Stern Y, Mintz A, Wisniewski T, Acosta E, Pollina J, Katsikoumbas M, Bell KL, Pelton GH, Deliyannides D, Prasad KM, Huey ED. Antiviral therapy: Valacyclovir Treatment of Alzheimer's Disease (VALAD) Trial: protocol for a randomised, double-blind,placebo-controlled, treatment trial. BMJ Open 2020; 10:e032112. [PMID: 32034019 PMCID: PMC7045215 DOI: 10.1136/bmjopen-2019-032112] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 10/16/2019] [Accepted: 11/26/2019] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION After infection, herpes simplex virus-1 (HSV1) becomes latent in the trigeminal ganglion and can enter the brain via retrograde axonal transport. Recurrent reactivation of HSV1 may lead to neurodegeneration and Alzheimer's disease (AD) pathology. HSV1 (oral herpes) and HSV2 (genital herpes) can trigger amyloid beta-protein (Aβ) aggregation and HSV1 DNA is common in amyloid plaques. Anti-HSV drugs reduce Aβ and phosphorylated tau accumulation in cell-culture models. Cognitive impairment is greater in patients with HSV seropositive, and antiviral drugs show robust efficacy against peripheral HSV infection. Recent studies of electronic health records databases demonstrate that HSV infections increase dementia risk, and that antiviral medication treatment reduces this risk. The generic antiviral drug valacyclovir was superior to placebo in improving memory in a schizophrenia pilot trial but has not been tested in AD. METHODS AND ANALYSIS In patients with mild AD who test positive for HSV1 or HSV2 serum antibodies, valacyclovir, repurposed as an anti-AD drug, will be compared with placebo (lactose pills) in 130 patients (65 valacyclovir and 65 placebo) in a randomised, double-blind, 78-week phase II proof-of-concept trial. Patients on valacyclovir, dose-titrated from 2 g to a targeted oral dose of 4 g daily, compared with placebo, are hypothesised to show smaller cognitive and functional decline, and, using 18F-Florbetapir positron emission tomography (PET) and 18F-MK-6240 PET imaging, to show less amyloid and tau accumulation, respectively. In the lumbar puncture subsample, cerebrospinal fluid acyclovir will be assayed to assess central nervous system valacyclovir penetration. ETHICS AND DISSEMINATION The trial is being overseen by the New York State Psychiatric Institute Institutional Review Board (protocol 7537), the National Institute on Ageing, and the Data Safety Monitoring Board. Written informed consent is obtained for all subjects. Results will be disseminated via publication, clinicaltrials.gov, media and conferences. TRIAL REGISTRATION NUMBER ClinicalTrials.gov identifier (NCT03282916) Pre-results.
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Affiliation(s)
- D P Devanand
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Howard Andrews
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
- Department of Biostatistics, Columbia University Medical Center, New York, New York, USA
| | - William C Kreisl
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Qolamreza Razlighi
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Anne Gershon
- Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Yaakov Stern
- Department of Psychiatry, Columbia University, New York, New York, USA
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Akiva Mintz
- Department of Radiology, Columbia University Medical Center, New York, New York, USA
| | - Thomas Wisniewski
- Center for Cognitive Neurology, Departments of Neurology, New York University Medical Center, New York, New York, USA
| | - Edward Acosta
- Department of Pharmacology, University of Alabama, Tuscaloosa, Alabama, USA
| | - Julianna Pollina
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
| | - Mariasofia Katsikoumbas
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
| | - Karen L Bell
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Gregory H Pelton
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
| | - Deborah Deliyannides
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
| | - K M Prasad
- Departments of Psychiatry and Bioengineering, University of Pittsburgh Swanson School of Engineering, Pittsburgh, Pennsylvania, USA
| | - Edward D Huey
- Department of Psychiatry, Columbia University, New York, New York, USA
- Division of Geriatric Psychiatry, New York State Psychiatric Institute, New York, New York, USA
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, New York, USA
- Department of Neurology, Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University College of Physicians and Surgeons, New York, New York, USA
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18
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Wolthuis DFGJ, de Mare S, Verhave JC. Limited skin lesions in a haemodialysis patient. Eur J Intern Med 2020; 72:94-95. [PMID: 31901296 DOI: 10.1016/j.ejim.2019.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 12/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- David F G J Wolthuis
- Department of Internal Medicine, Rijnstate Hospital, P.O. Box 9555, 6800 TA Arnhem, the Netherlands
| | - Saskia de Mare
- Department of Dermatology, Rijnstate Hospital, P.O. Box 9555, 6800 TA Arnhem, the Netherlands
| | - Jacobien C Verhave
- Department of Internal Medicine, Rijnstate Hospital, P.O. Box 9555, 6800 TA Arnhem, the Netherlands.
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19
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Kawabe Matsukawa M, Suzuki Y, Ikuma D, Suwabe T, Uesaka Y, Sugimoto I. [Acyclovir encephalopathy in a peritoneal dialysis patient despite adjusting the dose of oral acyclovir: a case report]. Rinsho Shinkeigaku 2019; 59:834-839. [PMID: 31761838 DOI: 10.5692/clinicalneurol.cn-001355] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
We report a case of acyclovir encephalopathy in a 77-year-old man who was introduced to peritoneal dialysis three years earlier. He developed herpes zoster and was treated with acyclovir (ACV) at 800 mg daily per oral. Two days later, he developed consciousness disturbance, hallucinations and asterixis. Acyclovir was stopped and continuous ambulatory peritoneal dialysis (CAPD) was switched to hemodialysis, which resulted in the resolution of his symptoms. Because the optimal dose of ACV varies among individuals depending on the bioavailability of ACV and metabolic enzyme activity, ACV encephalopathy can occur even when the acyclovir dose is modified according to the renal function of the affected patient. Because CAPD provides a poorer ACV clearance than hemodialysis, CAPD patients tend to have a higher risk of developing ACV encephalopathy and to recover more slowly. If CAPD patients develop ACV encephalopathy, a temporary change in the type of dialysis to hemodialysis should be considered.
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Affiliation(s)
| | - Yuya Suzuki
- Department of Neurology, Toranomon Hospital Kajigaya
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20
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He QE, Xia M, Ying GH, He XL, Chen JH, Yang Y. Severe mental disorders following anti-retroviral treatment in a patient on peritoneal dialysis: A case report and literature review. World J Clin Cases 2019; 7:3329-3334. [PMID: 31667187 PMCID: PMC6819294 DOI: 10.12998/wjcc.v7.i20.3329] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 08/23/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Antiviral drugs are widely used in populations with viral infection caused by immunologic inadequacy. Because these drugs are mainly metabolized by the kidneys, patients with renal failure undergoing renal replacement therapy are prone to drug adverse effects and poisoning. Severe neurotoxicity caused by antiviral drugs is a rare but life-threatening complication.
CASE SUMMARY This study reported one male patient on peritoneal dialysis who suffered from severe mental disorders after receiving an overdose of acyclovir and valacyclovir for the treatment of herpes zoster. The literature review suggested that hemodialysis is better than peritoneal dialysis to clear acyclovir from the circulation. The patient died after his consciousness deteriorated despite peritoneal dialysis and continuous blood purification.
CONCLUSION This case emphasizes cautiousness when using anti-retroviral drugs in patients with uremia. Hemodialysis is optimal method to remove the drugs.
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Affiliation(s)
- Qi-En He
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, the Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Nephrology, Beilun People's Hospital, Ningbo 315000, Zhejiang Province, China
| | - Min Xia
- Department of Nephrology, Beilun People's Hospital, Ningbo 315000, Zhejiang Province, China
| | - Guang-Hui Ying
- Department of Nephrology, Beilun People's Hospital, Ningbo 315000, Zhejiang Province, China
| | - Xue-Lin He
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, the Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Nephrology, Beilun People's Hospital, Ningbo 315000, Zhejiang Province, China
| | - Jiang-Hua Chen
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, the Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Yi Yang
- Kidney Disease Center, the First Affiliated Hospital, College of Medicine, Zhejiang University, Key Laboratory of Kidney Disease Prevention and Control Technology, Zhejiang Province, the Third Grade Laboratory Under the National State, Administration of Traditional Chinese Medicine, Hangzhou 310000, Zhejiang Province, China
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21
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Inaba I, Kondo Y, Iwasaki S, Tsuruhashi S, Akaishi A, Morita K, Oniki K, Saruwatari J, Ishitsuka Y, Irie T. Risk Evaluation for Acute Kidney Injury Induced by the Concomitant Use of Valacyclovir, Analgesics, and Renin-Angiotensin System Inhibitors: The Detection of Signals of Drug-Drug Interactions. Front Pharmacol 2019; 10:874. [PMID: 31440161 PMCID: PMC6694181 DOI: 10.3389/fphar.2019.00874] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/09/2019] [Indexed: 02/04/2023] Open
Abstract
Background: Drug-related acute kidney disease is a common side effect of valacyclovir (VACV) treatment. Although analgesics are frequently administered concomitantly with VACV to treat the pain of herpes zoster, the differences between nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen in relation to VACV-related acute kidney injury (AKI) are unclear. The risk for AKI with concomitant use of VACV and renin–angiotensin system (RAS) inhibitors that can cause AKI via a similar mechanism to NSAIDs is also unknown. We therefore evaluated the association between concomitant use of these drugs and VACV-related AKI, which was characterized according to the Japanese Adverse Drug Event Report (JADER) database. Methods: We analyzed data from the JADER database, which is a spontaneous reporting system. The reporting odds ratio was used to evaluate the signals of AKI. Results: A high proportion of VACV-related AKI cases occurred in summer. There was an increase in AKI signal in cases with concomitant use of VACV and NSAIDs, while no increase was detected in cases with concomitant use of VACV and acetaminophen. AKI events in cases with concomitant use of VACV and NSAIDs were more frequent in older and female patients and those with hypertension. Additionally, a signal increase for VACV-related AKI was observed with concomitant use of RAS inhibitors, with or without NSAIDs. Conclusions: We identified a seasonal variation in VACV-related AKI. Additionally, our findings indicate that acetaminophen might represent a safer analgesic than NSAIDs with respect to VACV-related AKI. We also identified candidate risk factors for AKI with concomitant use of NSAIDs, such as older age, female sex, and hypertension. Although further studies are warranted, our findings highlight the need to consider concomitant drug use and seasonal factors that lead to urinary output loss so that VACV-related AKI can be avoided.
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Affiliation(s)
- Ichiro Inaba
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan.,Central Pharmacy Nagamine, Kumamoto, Japan
| | - Yuki Kondo
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Shinya Iwasaki
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Satoko Tsuruhashi
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Ayano Akaishi
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kazuya Morita
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Kentaro Oniki
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Junji Saruwatari
- Division of Pharmacology and Therapeutics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Yoichi Ishitsuka
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
| | - Tetsumi Irie
- Department of Clinical Chemistry and Informatics, Graduate School of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan.,Center for Clinical Pharmaceutical Sciences, Faculty of Pharmaceutical Sciences, Kumamoto University, Kumamoto, Japan
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Neurologic Acyclovir Toxicity in the Absence of Kidney Injury. J Emerg Med 2019; 57:e35-e39. [DOI: 10.1016/j.jemermed.2019.03.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/19/2019] [Accepted: 03/30/2019] [Indexed: 11/13/2022]
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23
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Benassi-Zanqueta É, Marques CF, Valone LM, Pellegrini BL, Bauermeister A, Ferreira ICP, Lopes NP, Nakamura CV, Dias Filho BP, Natali MRM, Ueda-Nakamura T. Evaluation of anti-HSV-1 activity and toxicity of hydroethanolic extract of Tanacetum parthenium (L.) Sch.Bip. (Asteraceae). PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2019; 55:249-254. [PMID: 30668436 DOI: 10.1016/j.phymed.2018.06.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Revised: 05/24/2018] [Accepted: 06/19/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Herpes simplex type 1 (HSV-1) is widely distributed throughout the world's population. The virus spreads through direct contact with an infected individual. After primary infection, the virus remains in a latent state, and the recurrence of herpetic lesions is common. Standard treatment is performed with nucleoside analogues, but the selection of resistant strains have occurred, thus requiring the continual search for new antiviral agents. Plant extracts, fractions, and isolated compounds are a good source for studying possible antiviral compounds. HYPOTHESIS Among plants with antiviral activity, the crude extract of aerial parts of Tanacetum parthenium (L.) Sch.Bip. (Asteraceae) have previously shown to inhibit HSV-1 infection in vitro. METHODS The present study investigated the chemical composition of a crude hydroethanolic extract (CHE) of T. parthenium, and in vivo safety and therapeutic efficacy against HSV-1 infection. RESULTS Liquid chromatography-mass spectrometry showed that the CHE was composed of phenolic acids (chlorogenic acids) and sesquiterpene lactones (parthenolide). Acute and subchronic toxicity and genotoxicity tests in vivo showed that oral CHE administration did not result in signs of toxicity, with no genotoxic potential. The CHE was also safe for topical administration, in which no irritation of the epidermis was observed in treated animals. Tests of topical and oral therapeutic efficacy showed that the CHE was effective against HSV-1 infection. Topical administration was the most effective, the results for which were comparable to acyclovir. CONCLUSION These findings indicate that the CHE from aerial parts of Tanacetum parthenium has in vivo anti-HSV-1 activity and is safe for oral and topical application.
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Affiliation(s)
- Érica Benassi-Zanqueta
- Department of Basic Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Larissa Machado Valone
- Department of Basic Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | | | - Anelize Bauermeister
- Department of Physics and Chemistry, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | | | - Norberto Peporine Lopes
- Department of Physics and Chemistry, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Celso Vataru Nakamura
- Department of Basic Health Sciences, State University of Maringá, Maringá, Paraná, Brazil
| | | | | | - Tania Ueda-Nakamura
- Department of Basic Health Sciences, State University of Maringá, Maringá, Paraná, Brazil.
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Yoshimura T, Kawasaki T, Shirota A, Saeki M, Okada Y, Okada H. Valacyclovir-induced Neurotoxicity in a Patient with a Preserved Renal Function. Intern Med 2018; 57:3213-3216. [PMID: 29877263 PMCID: PMC6262714 DOI: 10.2169/internalmedicine.0403-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Valacyclovir, a prodrug of acyclovir, is the first-line treatment for herpes zoster, but the renal function must be monitored, because acyclovir is metabolized by the kidneys. We herein report a case of valacyclovir-induced neurotoxicity with no preceding renal impairment. An 88-year-old man was admitted because of an impaired consciousness after the administration of valacyclovir at 3,000 mg daily for herpes zoster on the chest. His consciousness level gradually improved with hydration and valacyclovir withdrawal. It was later confirmed that the level of acyclovir on admission had been 35.45 μg/mL in the blood and 36.45 μg/mL in the cerebrospinal fluid.
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Affiliation(s)
- Takashi Yoshimura
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
| | - Tatsuya Kawasaki
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
| | - Ayumi Shirota
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
| | - Masashi Saeki
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
| | - Yuki Okada
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
| | - Hiroshi Okada
- Department of General Internal Medicine, Matsushita Memorial Hospital, Japan
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When a Seemingly Harmless Prescription Turns into Toxicity. Case Rep Med 2018; 2018:9724390. [PMID: 30305816 PMCID: PMC6165624 DOI: 10.1155/2018/9724390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2018] [Revised: 08/19/2018] [Accepted: 09/03/2018] [Indexed: 11/23/2022] Open
Abstract
Valacyclovir neurotoxicity is commonly seen in the elderly and those with impaired renal function. Differential diagnosis can be challenging as a myriad of medical conditions, including herpes zoster virus associated encephalitis, may present in a similar fashion. We present a case of a 71-year-old male who presented with altered mental status in the setting of recent herpes zoster eruption. His condition was attributed to valacyclovir neurotoxicity, and initiation of appropriate supportive therapy was met with complete resolution of symptoms and normalization of cognitive function.
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Abstract
PURPOSE OF REVIEW Viruses, particularly herpes simplex virus (HSV), may be a cause of Alzheimer's disease (AD). The evidence supporting the viral hypothesis suggests that antiviral treatment trials, which have not been conducted, are warranted. RECENT FINDINGS HSV1 (oral herpes) and HSV2 (genital herpes) can trigger amyloid aggregation, and their DNA is common in amyloid plaques. HSV1 reactivation is associated with tau hyperphosphorylation and possibly tau propagation. Anti-HSV drugs reduce Aβ and p-tau accumulation in infected mouse brains. Clinically, after the initial oral infection, herpes simplex virus-1 (HSV1) becomes latent in the trigeminal ganglion and recurrent reactivation may produce neuronal damage and AD pathology. Clinical studies show cognitive impairment in HSV seropositive patients, and antiviral drugs show strong efficacy against HSV. An antiviral treatment trial in AD is clearly warranted. A phase II treatment trial with valacyclovir, an anti-HSV drug, recently began with evaluation of clinical and biomarker outcomes.
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Murakami T, Akimoto T, Okada M, Hishida E, Sugase T, Miki A, Kohara M, Yoshizawa H, Masuda T, Kobayashi T, Saito O, Muto S, Nagata D. Valacyclovir Neurotoxicity and Nephrotoxicity in an Elderly Patient Complicated by Hyponatremia. Drug Target Insights 2018; 12:1177392818782899. [PMID: 30013310 PMCID: PMC6043912 DOI: 10.1177/1177392818782899] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Accepted: 05/16/2018] [Indexed: 11/17/2022] Open
Abstract
A 66-year-old women with no history of renal disease was admitted due to a coma and acute kidney injury with a serum creatinine level of 7.44 mg/dL which were ascribed to valacyclovir neurotoxicity and nephrotoxicity, respectively. She had received valacyclovir at a standard dosage for the treatment of herpes zoster and was finally discharged, having fully returned to her normal baseline mental status with a recovered serum creatinine level of 0.68 mg/dL. We feel that awareness of this pathology remains a challenge for physicians and therefore strongly recommend the further accumulation of experiences similar to our own. Our experience underscores the pitfalls of administering valacyclovir to elderly patients who barely appear to have a favorable renal function. Several concerns regarding the therapeutic management, including blood purification strategies, that emerged in this case are also discussed.
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Affiliation(s)
- Takuya Murakami
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Mari Okada
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Erika Hishida
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Taro Sugase
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Atsushi Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Marina Kohara
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Hiromichi Yoshizawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takahiro Masuda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Takahisa Kobayashi
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Osamu Saito
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke, Japan
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Fracaso renal agudo y neurotoxicidad severa tras sobredosis accidental por valaciclovir en población geriátrica: a propósito de un caso. Nefrologia 2018. [DOI: 10.1016/j.nefro.2017.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Prasad B, McIsaac M, Toppings J. Valacyclovir-associated neurotoxicity treated with intensification of peritoneal dialysis. BMJ Case Rep 2017; 2017:bcr-2017-220678. [PMID: 28765478 DOI: 10.1136/bcr-2017-220678] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
We report a 57-year-old woman with end-stage renal disease (ESRD) on maintenance peritoneal dialysis (PD), who presented to the emergency room (ER) by ambulance with complaints of confusion and altered sensorium for 48 hours. She had been reviewed in a walk-in clinic 72 hours earlier and had been prescribed the standard 1000 mg three times per day of valacyclovir for an acute attack of shingles instead of 500 mg once a day on ESRD. In the ER, she received further 500 mg of intravenous acyclovir as herpes encephalitis was clinically suspected. CT of the brain and lumbar puncture were non-contributory to the diagnosis. Valacyclovir and acyclovir were discontinued when the diagnosis of valacyclovir-associated neurotoxicity became clinically evident. As the patient's Glasgow Coma Scale declined, we intensified her PD regimen from one to six exchanges per day and 24 hours later there was a significant neurological improvement.
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Affiliation(s)
- Bhanu Prasad
- Department of Nephrology, Regina Qu Appele Health region, Regina, Canada
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Akimoto T, Muto S, Nagata D. Bilateral herpes zoster in a patient with end-stage kidney disease. Int Med Case Rep J 2017; 10:209-212. [PMID: 28684923 PMCID: PMC5484569 DOI: 10.2147/imcrj.s138398] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Herpes zoster (HZ) is caused by the reactivation of a latent varicella-zoster virus (VZV) infection within the cranial or dorsal root ganglia. The cutaneous lesions of HZ are typically limited to a single dermatome, while non-contiguous HZ involving two or more dermatomes is a very rare clinical entity. In this report, we describe a case of HZ involving the left and right side of the abdomen corresponding to the T11 dermatome in a 63-year-old man on chronic peritoneal dialysis. The characteristic cutaneous manifestation encouraged us to ascribe the disease to HZ duplex bilateralis, and the patient was given a single dose of oral valacyclovir and achieved a favorable outcome. The therapeutic concerns regarding the reactivation of VZV in patients with end-stage kidney disease are also discussed.
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Affiliation(s)
- Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Shimotsuke-Shi, Tochigi, Japan
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de la Parra-Colin P, Garza-Leon M, Ortiz-Nieva G, Barrientos-Gutierrez T, Lindsley K. Oral antivirals for preventing recurrence of herpes simplex virus keratitis. Hippokratia 2017. [DOI: 10.1002/14651858.cd010556.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Paola de la Parra-Colin
- La Raza Medical Center; Cornea and Ocular Surface Clinic, Ophthalmology Department; Mexican Institute of Social Security (IMSS) Mexico City Mexico
| | - Manuel Garza-Leon
- Destellos de Luz non-profit Foundation; Cornea and Uveitis Department; Av. Lázaro Cárdenas # 2600 Ote. Col. Valle Oriente San Pedro Garza Garcia Nuevo León Mexico 66269
| | - Gabriela Ortiz-Nieva
- Brighton and Sussex University Hospitals; Sussex Eye Hospital; Eastern Brighton Road Brighton UK BN2 5BF
| | - Tonatiuh Barrientos-Gutierrez
- National Institute of Public Health; Tobacco Research Department; 7a Cerrada de Fray Pedro de Gante #50 Col Seccion XVI, Tlalpan Mexico City Mexico City Mexico 14000
| | - Kristina Lindsley
- Johns Hopkins Bloomberg School of Public Health; Department of Epidemiology; 615 North Wolfe Street, Mail Room E6132 Baltimore Maryland USA 21205
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Ericson JE, Gostelow M, Autmizguine J, Hornik CP, Clark RH, Benjamin DK, Smith PB. Safety of High-dose Acyclovir in Infants With Suspected and Confirmed Neonatal Herpes Simplex Virus Infections. Pediatr Infect Dis J 2017; 36:369-373. [PMID: 27977557 PMCID: PMC5348260 DOI: 10.1097/inf.0000000000001451] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acyclovir is used to treat herpes simplex virus disease in infants. Treatment with high-dose acyclovir, 60 mg/kg/d, is recommended; however, the safety of this dosage has not been assessed in the past 15 years, and this dosage is not currently approved for infants by the US Food and Drug Administration. METHODS We included infants with neonatal herpes simplex virus disease treated with ≥14 days of intravenous acyclovir starting in the first 120 days of life admitted to 1 of 42 neonatal intensive care units managed by the Pediatrix Medical Group between 2002 and 2012. We determined the frequency and proportion of infants with clinical and laboratory adverse events (AEs) as well as the number and proportion of infant days with laboratory AEs occurring during acyclovir exposure. RESULTS We identified 89 infants during the study period with 1658 days of acyclovir exposure. Almost all received high-dose acyclovir therapy (79/89, 89%). The most common clinical AEs were hypotension and seizure, both occurring in 9% of infants. Thrombocytopenia was the most common laboratory AE occurring in 25% of infants and on 9% of infant-days. Elevated creatinine occurred in 2% of infants and 0.2% of infant-days and no infants developed renal failure requiring dialysis. Overall, 45% of infants had ≥1 AE. CONCLUSIONS In this cohort of infants treated during the high-dose acyclovir era, AEs were common but usually not severe. Many of the AEs reported in this cohort may be related to the underlying infection rather than due to acyclovir exposure.
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Affiliation(s)
- Jessica E. Ericson
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Pennsylvania State University College of Medicine, Hershey, PA
| | | | - Julie Autmizguine
- Department of Pediatrics, CHU Sainte Justine, University of Montreal, Montreal, Quebec
- Department of Pharmacology, University of Montreal, Montreal, Quebec
| | - Christoph P. Hornik
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - Reese H. Clark
- Pediatrix-Obstetrix Center for Research and Education, Sunrise, FL
| | - Daniel K. Benjamin
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
| | - P. Brian Smith
- Duke Clinical Research Institute, Durham, NC
- Department of Pediatrics, Duke University, Durham, NC
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Watson WA, Rhodes NJ, Echenique IA, Angarone MP, Scheetz MH. Resolution of acyclovir-associated neurotoxicity with the aid of improved clearance estimates using a Bayesian approach: A case report and review of the literature. J Clin Pharm Ther 2017; 42:350-355. [PMID: 28370067 DOI: 10.1111/jcpt.12520] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2016] [Accepted: 02/19/2017] [Indexed: 12/31/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Neurotoxicity is a side effect of acyclovir. We report the first case, to our knowledge, whereby Bayesian-informed clearance estimates supported a therapeutic intervention for acyclovir-associated neurotoxicity. CASE SUMMARY A 62-year-old male with the diagnosis of disseminated zoster was being treated with intravenous (IV) acyclovir when he developed symptoms of acute neurotoxicity. Acyclovir had been dose-adjusted for renal dysfunction according to traditional creatinine clearance estimates; however, as the patient was also on vancomycin, Bayesian estimates of vancomycin clearances were performed, which revealed a 2-fold lower creatinine clearance. In response to the Bayesian estimates, acyclovir was discontinued, and improvements in mentation were noted within 24 hours. WHAT IS NEW AND CONCLUSION Alternate approaches to estimate renal function beyond Cockcroft-Gault, such as a Bayesian approach used in our patient, should be considered when population estimates are likely to be inaccurate and potentially dangerous to the patient.
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Affiliation(s)
- W A Watson
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA
| | - N J Rhodes
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, FL, USA
| | - I A Echenique
- Department of Infectious Disease, Cleveland Clinic Florida, Weston, FL, USA
| | - M P Angarone
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - M H Scheetz
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, IL, USA.,Department of Pharmacy Practice, Midwestern University, Chicago College of Pharmacy, Downers Grove, FL, USA
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34
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Chen LK, Arai H, Chen LY, Chou MY, Djauzi S, Dong B, Kojima T, Kwon KT, Leong HN, Leung EMF, Liang CK, Liu X, Mathai D, Pan JY, Peng LN, Poblete ERS, Poi PJH, Reid S, Tantawichien T, Won CW. Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific. BMC Infect Dis 2017; 17:213. [PMID: 28298208 PMCID: PMC5353949 DOI: 10.1186/s12879-017-2198-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 01/09/2017] [Indexed: 02/05/2023] Open
Abstract
Background Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region. Methods We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines. Results From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand. HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation. Conclusions Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Liang-Kung Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan. .,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.
| | - Hidenori Arai
- National Center for Geriatrics and Gerontology, 7-340 Morioka-cho, Obu, Aichi, 474-8511, Japan
| | - Liang-Yu Chen
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan
| | - Ming-Yueh Chou
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan
| | - Samsuridjal Djauzi
- Department of Internal Medicine, Faculty of Medicine, University of Indonesia, Salemba Raya No. 6, Jakarta, 10430, Indonesia
| | - Birong Dong
- The Center of Gerontology and Geriatrics, West China Medical School/West China Hospital, Sichuan University, No. 37 Guo Xue Xiang, Renmin Nan Lu, Chengdu, Sichuan, 610041, China
| | - Taro Kojima
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1, Jongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Ki Tae Kwon
- Division of Infectious Diseases, Daegu Fatima Hospital, 99 Ayang-ro, Dong-gu, Daegu, 710-600, Korea
| | - Hoe Nam Leong
- Rophi Clinic, 38 Irrawaddy Rd. #07-54/55, Mount Elizabeth Novena Specialist Centre, Singapore, 329563, Singapore
| | - Edward M F Leung
- Geriatric Medicine Centre (Healthy Ageing), Hong Kong Sanatorium and Hospital, 2 Village Rd. Happy Valley, Hong Kong S.A.R., China
| | - Chih-Kuang Liang
- Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan.,Center for Geriatrics and Gerontology, Kaohsiung Veterans General Hospital, No. 386 Ta-Chun 1st Rd., Kaohsiung, 81362, Taiwan.,Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Xiaohong Liu
- Division of Geriatrics, Department of Internal Medicine, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Dilip Mathai
- Apollo Institute of Medical Sciences and Research, Apollo Health City Campus, Jubilee Hills, Hyderabad, 500096, India
| | - Jiun Yit Pan
- National Skin Centre, 1 Mandalay Rd., Singapore, 308205, Singapore
| | - Li-Ning Peng
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shih-Pai Rd., Taipei, 11217, Taiwan.,Aging and Health Research Center, National Yang Ming University, Taipei, Taiwan
| | - Eduardo Rommel S Poblete
- Geriatric Center, St. Luke's Medical Center, 279 E. Rodriguez Sr. Ave., Quezon City, 1102, Philippines
| | - Philip J H Poi
- Division of Geriatrics, Department of Medicine, University Malaya Medical Centre, Lembah Pantai, 59100, Kuala Lumpur, Malaysia
| | - Stewart Reid
- Ropata Medical Centre, Lower Hutt, 5010, New Zealand
| | - Terapong Tantawichien
- Division of Infectious Diseases, Department of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand
| | - Chang Won Won
- Department of Family Medicine, College of Medicine, Kyung Hee University, 1 Hoigi-dong, Dongdaemun-gu, Seoul, 130-720, Korea
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Zhang Y, Cong Y, Teng Y. Acute renal injury induced by valacyclovir hydrochloride: A case report. Exp Ther Med 2017; 12:4025-4028. [PMID: 28101180 DOI: 10.3892/etm.2016.3905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/06/2016] [Indexed: 11/06/2022] Open
Abstract
Acyclovir has been a frequently used antiviral agent in the clinical treatment of leukemia, acute encephalitis, malignant tumor and herpes simplex. The adverse effects of this drug have been widely described in clinical practice. In the present study, a case of a 35-year-old female patient diagnosed with herpes simplex, who developed acute renal injury following treatment with valacyclovir hydrochloride, is described. Kidney biopsy, light microscopy and laboratory examination were performed, and all findings revealed the signs of evident vacuolar degeneration of capillary endothelial and renal tubular epithelial cells, erythrocyte aggregation in partial renal tubule and microvilli exfoliation from epithelial cells. Renal interstitial edema was clearly identified. The clinical evidence observed from this female patient indicated that renal functions should be closely monitored during valacyclovir hydrochloride administration. A variety of effective measures, such as hydration, alkalizing urine, promoting the discharge of medication and the use of antagonists are recommended following the administration of antiviral agents.
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Affiliation(s)
- Yanning Zhang
- Department of Nephrology, People's Liberation Army No. 202 Hospital, Shenyang, Liaoning 110000, P.R. China
| | - Yuxi Cong
- Department of Nephrology, People's Liberation Army No. 202 Hospital, Shenyang, Liaoning 110000, P.R. China
| | - Yan Teng
- Department of Nephrology, People's Liberation Army No. 202 Hospital, Shenyang, Liaoning 110000, P.R. China
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Abstract
We present the case of a 52-year-old man with hypertension, diastolic congestive heart failure, end-stage renal disease on hemodialysis 3 times a week and a remote history of a hemorrhagic stroke who presented to the emergency department with a vesicular rash on his left arm. The rash was observed to be in a dermatomal distribution, and a diagnosis of herpes zoster was made. The patient was discharged home on valacyclovir 1 g 3 times a day for a duration of 7 days. The patient took 2 doses of valacyclovir before presenting to the hospital again with irritability and hallucinations. Over the next several days, the patient's neurologic status declined and he became disoriented and increasingly somnolent. Because of a concern for varicella zoster virus (VZV) or herpes simplex virus (HSV) meningoencephalitis, acyclovir was initiated intravenously at 600 mg (10 mg/kg) for every 12 hours. Computed tomography and magnetic resonance imaging of the brain failed to reveal an acute process. Electroencephalogram was interpreted as seizure activity versus metabolic encephalopathy. Lumbar puncture was not suggestive for meningitis, subarachnoid hemorrhage, or HSV/VZV infection. The patient subsequently had a witnessed seizure during dialysis and was felt to have status epilepticus due to acyclovir and valacyclovir neurotoxicity. The patient underwent daily hemodialysis for removal of the drug and eventually made a full neurologic recovery. Our case highlights that acyclovir neurotoxicity can result in status epilepticus, hallucinations, and altered consciousness. Differentiating acyclovir neurotoxicity from HSV or VZV meningoencephalitis is of crucial importance because the symptoms are similar but the management is vastly different.
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37
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Singer EJ, Thames AD. Neurobehavioral Manifestations of Human Immunodeficiency Virus/AIDS: Diagnosis and Treatment. Neurol Clin 2016; 34:33-53. [PMID: 26613994 DOI: 10.1016/j.ncl.2015.08.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Behavioral disorders are common in persons infected with human immunodeficiency virus (HIV). The differential includes preexisting psychiatric diseases, substance abuse, direct effects of HIV infection, opportunistic infection, and the adverse effects of medical therapies. Many patients have more than one contributing or comorbid problem to explain these behavioral changes. The differential should always include consideration of psychosocial, genetic, and medical causes of disease. Treatment strategies must take into account the coadministration of antiretroviral therapy and the specific neurologic problems common in patients infected with HIV.
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Affiliation(s)
- Elyse J Singer
- NeuroInfectious Diseases Program, UCLA National Neurological AIDS Bank, David Geffen School of Medicine at UCLA, 710 Westwood Plaza, Room A129, Los Angeles, CA 90095, USA.
| | - April D Thames
- Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at UCLA, 740 Westwood Plaza, C8-746, Los Angeles, CA 90095, USA
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38
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Nakatani M, Tsukino M, Takahashi R, Ikeda A. [Periodic synchronous discharge occurred in an elderly with acute valacyclovir-associated encephalopathy]. Rinsho Shinkeigaku 2016; 56:504-507. [PMID: 27356736 DOI: 10.5692/clinicalneurol.cn-000892] [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: 06/06/2023]
Abstract
An 81-year-old woman suffering from sarcoidosis, chronic renal failure caused by hypertention was treated by valacyclovir 500 mg/day, for the diagnosis of herpes zoster of her right back. Her consciousness gradually became worse, and 3 days after taking the drug, she was sent to the emergency department of the hospital. Her conscious level was E2V2M5 (Glasgow Coma Scale) and myoclonus especially in her lower extremities occurred. Head CT and MRI show no obvious, acute abnormal findings other than chronic ischemic lesions, while an electroencephalogram (EEG) shows periodic synchronous discharges (PSDs) and disorganized background activity. Based on these findings, she was diagnosed as valacyclovir-associated acute encephalopathy. After conservative therapy of maintenance hemodialysis, her consciousness gradually improved, and PSDs disappeared accordingly and background activity of EEG became improved. In this case report, we presented valacyclovir-associated neurotoxicity with PSDs in EEG as potentially a surrogate marker. We should be cautious to use valaciclovir which may cause drug-induced encephalopathy especially in elderly or patients with renal failure even though the dose was adjusted in advance.
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Abstract
Introduction Antimicrobial-induced cognitive side effects are often overlooked or underreported. Literature often reports symptoms of antimicrobial-induced cognitive impairment under more general blanket terms, such as neuropsychiatric side effects, neurotoxicity, or drug-induced delirium or encephalopathy. Methods A PubMed search using terms including antibiotics, antifungals, antivirals, antimalarials, side effects, cognitive, neurotoxicity, encephalopathy, and delirium was conducted. Respectively, symptoms of cognitive impairment were teased out of the multiple neurologic complications presented for each case and reported based on antimicrobial class. Articles were excluded if they focused solely on neuropsychiatric side effects such as seizures, psychosis, hallucinations, or mood disturbances, were conducted in animals, or involved antiretroviral medication therapies. Results Of over 50 case reviews, case reports, retrospective chart reviews, and prospective cohort studies analyzed, 25 were deemed appropriate for purposes of this review. Common antimicrobial-induced cognitive side effects for all antimicrobial classes included confusion, delirium, encephalopathy, and impaired concentration or attention. Recurring risk factors included, but were not limited to, older age and renal impairment. Mechanisms of cognitive impairment were relatively specific to each antimicrobial class. Discussion Awareness of the potential for antimicrobial-induced cognitive side effects, including the general time frame of symptom onset and symptom presentation, is critical in challenging patient cases. This review article aims to summarize the risk factors, clinical symptoms, mechanisms, and management of antimicrobial-induced cognitive side effects. Pharmacists can play a key role in prevention through adjustment of medications for renal or hepatic dysfunction, avoidance of polypharmacy, and knowledge of critical drug interactions that may precipitate cognitive decline.
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Affiliation(s)
- Amanda Warstler
- PGY2 Psychiatric Pharmacy Resident, Department of Veterans Affairs, Tennessee Valley Healthcare System, Murfreesboro, Tennessee,
| | - Jennifer Bean
- Clinical Psychiatric Pharmacist, Department of Veterans Affairs, Tennessee Valley Healthcare System, Murfreesboro, Tennessee
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Fil LJ, Sud P, Sattler S. A Massive Overdose of Dalfampridine. West J Emerg Med 2016; 16:1177-9. [PMID: 26759675 PMCID: PMC4703168 DOI: 10.5811/westjem.2015.8.26127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Revised: 07/31/2015] [Accepted: 08/19/2015] [Indexed: 11/11/2022] Open
Abstract
Multiple sclerosis (MS) is an immune mediated inflammatory disease that attacks myelinated axons in the central nervous system. Dalfampridine (4-aminopyridine) was approved by the Food and Drug Administration in January 2010 for treatment of MS. Our patient was a 34-year-old male with a history of MS, who was brought to the emergency department after being found unresponsive. His current medications were valacyclovir, temazepam, dalfampridine (4-AP) and a tysabri intravenous (IV) infusion. Fifteen minutes after arrival the patient seized. The seizures were refractory to benzodiazepines, barbiturates and phenytoin. The 4-AP level was 530 ng/mL (25 ng/mL and 49 ng/mL). The patient stopped seizing on hospital day 3 and was discharged 14 days later with normal mental status and neurologic exam. 4-AP is a potassium channel blocker that blocks the potassium ion current of repolarization following an action potential. The blockade of the potassium channel at the level of the membrane widens the action potential and enhances the release of acetylcholine, thus increasing post-synaptic action potentials. The treatment of patients with 4-AP overdose is supportive. Animal data suggest that patients with toxic levels of 4-AP may respond to phenytoin. Our case illustrates the highest recorded level of 4-AP in an overdose. Our patient appeared to be refractory to a combination of high doses of anticonvulsants and only improved with time.
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Affiliation(s)
- Laura J Fil
- North Shore University Hospital, Department of Emergency Medicine, Manhasset, New York
| | - Payal Sud
- Long Island Jewish Medical Center, Department of Emergency Medicine, New Hyde Park, New York
| | - Steven Sattler
- Good Samaritan Hospital, Department of Emergency Medicine, West Islip, New York
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Risky Business. PHYSICIAN ASSISTANT CLINICS 2016. [DOI: 10.1016/j.cpha.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Case files of the Harvard medical toxicology fellowship: valacyclovir neurotoxicity and unintentional overdose. J Med Toxicol 2015; 11:132-6. [PMID: 25539699 DOI: 10.1007/s13181-014-0457-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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Abstract
Valacyclovir is an oral antiviral agent being used more frequently than acyclovir because of the ease of administration and efficacy. Serious neuropsychiatric side effects have been demonstrated with the use of valacyclovir in renal failure patients. We report a case of valacyclovir neurotoxicity to emphasis the importance of dose adjustment in patients with chronic kidney disease and on dialysis.
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Death Delusions and Myoclonus: Acyclovir Toxicity. Am J Med 2015; 128:692-4. [PMID: 25784625 DOI: 10.1016/j.amjmed.2015.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 03/04/2015] [Accepted: 03/04/2015] [Indexed: 01/02/2023]
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Kinno R, Kurokawa S, Uchiyama M, Sakae Y, Kasai H, Ogata H, Kinugasa E. False-positive results obtained for immunoglobulin M antibody tests of cerebrospinal fluid for herpes simplex virus in a patient with varicella zoster virus encephalitis. Intern Med 2015; 54:2667-70. [PMID: 26466708 DOI: 10.2169/internalmedicine.54.4891] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 66-year-old man presented with a disturbed consciousness and seizure-like movements, followed by the initial symptoms of herpes zoster. Immunoglobulin (Ig) M antibodies to varicella zoster virus (VZV) as well as herpes simplex virus (HSV) were positive in the cerebrospinal fluid (CSF), whereas polymerase chain reaction of the CSF was positive for VZV-DNA but negative for HSV-DNA. The serum/CSF IgM ratio for VZV and HSV increased in association with a clinical improvement. This is a case report of a rare case of VZV encephalitis demonstrating false-positive results for IgM to HSV in the CSF. The increase in the serum/CSF IgM ratio possibly reflects a recovery from blood-brain barrier breakdown.
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Affiliation(s)
- Ryuta Kinno
- Department of Internal Medicine, Showa University Northern Yokohama Hospital, Japan
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Reversible mental status change and renal dysfunction associated with the use of high-dose oral valaciclovir therapy for acute retinal necrosis. Retin Cases Brief Rep 2014; 6:266-8. [PMID: 25389728 DOI: 10.1097/icb.0b013e3182252859] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to report the case of a patient with acute retinal necrosis who developed neurotoxicity while being treated with oral valaciclovir antiviral therapy. METHODS Testing used was clinical examination including fundus photographs, renal biochemistry, cerebrospinal fluid analysis, and renal ultrasound. RESULTS A 63-year-old, healthy, white woman was being treated with oral valaciclovir for acute retinal necrosis. Several days later, she developed visual hallucinations and confusion. Renal biochemistry was abnormal, and renal ultrasound was normal. Cerebrospinal fluid cellularity was normal, but cerebrospinal fluid 9-carboxymethoxymethylguanine, an aciclovir metabolite, level was elevated. Treatment was changed to intravenous aciclovir titrated based on serum aciclovir levels with intravenous fluid supplementation to good effect. CONCLUSION Regular monitoring of renal function and ample fluid intake are important when high doses of aciclovir/valaciclovir are used, even in patients with no previous history of renal failure. Monitoring of serum aciclovir level is useful in those with renal impairment to titrate doses, and high-dose oral valaciclovir should be used with caution.
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Lam NN, Fleet JL, McArthur E, Blake PG, Garg AX. Higher dose versus lower dose of antiviral therapy in the treatment of herpes zoster infection in the elderly: a matched retrospective population-based cohort study. BMC Pharmacol Toxicol 2014; 15:48. [PMID: 25186142 PMCID: PMC4158397 DOI: 10.1186/2050-6511-15-48] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/28/2014] [Indexed: 11/10/2022] Open
Abstract
Background Higher versus lower doses of antiviral drugs used to treat herpes zoster infection may lead to more adverse drug events in older adults, particularly those with chronic kidney disease. Methods We conducted a matched retrospective population-based cohort study of older adults (mean 77 years) in Ontario, Canada who initiated in the outpatient setting a higher (n = 23,256) or lower (n = 3,876) dose of one of three oral antivirals for the treatment of herpes zoster between 2002 and 2011. The primary outcome was hospitalization within 30 days with evidence of a computed tomography (CT) scan of the head (a proxy for acute neurotoxicity). The secondary outcome was 30-day all-cause mortality. Results A higher compared to lower dose of antiviral drug was not associated with an increased risk of hospitalization with an urgent CT scan of the head (247 [1.06%] events with higher dose versus 43 [1.11%] events with lower dose, relative risk 0.96, 95% confidence interval 0.69 to 1.33, p-value 0.79) and was not associated with a higher risk of all-cause mortality (63 [0.27%] events versus 15 [0.39%] events, relative risk 0.70, 95% confidence interval 0.40 to 1.23, p-value 0.21). Results were consistent in all subgroups, including those with and without chronic kidney disease. Conclusions Initiating a higher compared to a lower dose of an antiviral drug for the treatment of herpes zoster was not associated with an increased risk of adverse drug events. The findings support the safety of these drugs in older adults as currently prescribed in routine care.
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Affiliation(s)
- Ngan N Lam
- Department of Medicine, Division of Nephrology, Western University, London, ON N6A 3 K7, Canada.
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Sacchetti D, Alawadhi A, Albakour M, Rapose A. Herpes zoster encephalopathy or acyclovir neurotoxicity: a management dilemma. BMJ Case Rep 2014; 2014:bcr-2013-201941. [PMID: 24777077 DOI: 10.1136/bcr-2013-201941] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
This is a case report of a 69-year-old morbidly obese woman who presented with mental status changes after she was treated with acyclovir for shingles. The predominant symptoms were word-finding difficulties and visual hallucinations. Complicating her presentation was acyclovir-induced acute renal injury causing her creatinine level to rise up to 7.4 mg/dL. Acyclovir was discontinued on the suspicion of acyclovir neurotoxicity. Even though PCR for varicella zoster virus in the cerebrospinal fluid was positive, acyclovir was not restarted and the patient continued to improve and returned to her baseline.
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Affiliation(s)
- Daniel Sacchetti
- Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA
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Sagawa N, Tsurutani Y, Nomura K, Okuyama T, Kondo M, Sata A, Miyao M, Mizuno Y. [Acyclovir-induced neurotoxicity and acute kidney injury in an elderly diabetic patient treated with valacyclovir: report of a case]. Nihon Ronen Igakkai Zasshi 2014; 51:581-585. [PMID: 25749332 DOI: 10.3143/geriatrics.51.581] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
An 83-year-old Japanese man had a 29-year history of well-controlled diabetes mellitus. His HbA1c level was approximately 6.0%, with no microalbuminuria and a serum creatinine level seven days before admission of 0.8 mg/dl (eGFR: 69.67 ml/min/1.73 m(2)). Five days before admission, he visited an ophthalmologist with inflammation of the right palpebra and conjunctiva and began taking valacyclovir at a dose of 3,000 mg for the treatment of herpes zoster. Two days before admission, he was prescribed loxoprofen at a dose of 180 mg for a headache. One day prior to admission, he developed dysarthria, wandering and loss of appetite. He was subsequently admitted to our hospital with progressive deterioration of consciousness (Japan Coma Scale: II-20). On admission, he exhibited renal dysfunction, with a serum creatinine level of 5.11 mg/dl (eGFR: 9.16 ml/min/1.73 m(2)). Based on his diverse symptoms and current treatment with valacyclovir, the patient was diagnosed with acyclovir-induced neurotoxicity and his symptoms rapidly improved after hemodialysis. The serum acyclovir level on admission was found to be 9.25 μg/ml. Although acyclovir-induced neurotoxicity is commonly seen in elderly patients with renal dysfunction, there are also reports of this condition in patients with a normal renal function. Valacyclovir is frequently prescribed to the elderly to treat diseases such as herpes zoster. As valacyclovir induces renal dysfunction, which raises the serum acyclovir level to the toxic range, special attention must be paid when administering this drug in elderly subjects.
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Affiliation(s)
- Naoko Sagawa
- Division of Endocrinology and Metabolism, Kanto Central Hospital
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50
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Pugi A, Bonaiuti R, Maggini V, Moschini M, Tuccori M, Leone R, Rossi M, Motola D, Piccinni C, Ferrazin F, Sottosanti L, Mugelli A, Vannacci A, Lapi F. Safety profile of antiviral medications: A pharmacovigilance study using the Italian spontaneous-reporting database. Am J Health Syst Pharm 2013; 70:1039-46. [DOI: 10.2146/ajhp120665] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Alessandra Pugi
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Roberto Bonaiuti
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Valentina Maggini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Martina Moschini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Interuniversity Center of Molecular Medicine and Applied Biophysics (CIMMBA), University of Florence, and Pharmacovigilance Center of Tuscan County (PCTC), Florence, Italy
| | - Marco Tuccori
- PCTC, and Interdepartmental Center for Research in Clinical Pharmacology and Experimental Therapeutics, University of Pisa, Pisa, Italy
| | - Roberto Leone
- Clinical Pharmacology Unit, University of Verona, Verona, Italy
| | - Marco Rossi
- PCTC, and University Hospital of Siena, Siena, Italy
| | - Domenico Motola
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Piccinni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Fernanda Ferrazin
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Laura Sottosanti
- National Pharmacovigilance Office, Pharmacovigilance Unit, Italian Medicines Agency, Rome
| | - Alessandro Mugelli
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Alfredo Vannacci
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, and PCTC
| | - Francesco Lapi
- Department of Neuroscience, Psychology, Drug Research and Child Health, CIMMBA, PCTC, and the Center for Clinical Epidemiology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada
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