BNF for Children 2011-2012

324 5.3.2 Herpesvirus infections BNFC 2011–20125 Infectionsdose; if estimated glomerular filtration rate less than10 mL/minute/1.73 m 2 , 500 mg as a single dose); forsuppression of herpes simplex, 250 mg (500 mg inimmunocompromised or HIV-positive children) every24 hours if estimated glomerular filtration rate lessthan 30 mL/minute/1.73 m 2 ; reduce dose accordingto estimated glomerular filtration rate for cytomegalovirusprophylaxis following solid organ transplantation(consult product literature)Pregnancy see under AciclovirBreast-feeding see under AciclovirSide-effects see under Aciclovir but neurologicalreactions more frequent with high dosesLicensed use not licensed for treatment of herpeszoster in children; not licensed for treatment orsuppression of herpes simplex infection in immunocompromisedor HIV-positive childrenIndication and doseHerpes zoster in immunocompromised. By mouthChild 12–18 years 1 g 3 times daily for at least 7days (continue for 2 days after crusting of lesions)Treatment of herpes simplex. By mouthChild 12–18 years first episode, 500 mg twicedaily for 5 days, longer if new lesions appear duringtreatment or if healing incomplete (1 g twice dailyfor 10 days in immunocompromised or HIV-positivechildren); recurrent infection, 500 mg twicedaily for 3–5 days (1 g twice daily for 5–10 days inimmunocompromised or HIV-positive children)Treatment of herpes labialis. By mouthChild 12–18 years initially 2 g, then 2 g 12 hoursafter initial doseSuppression of herpes simplex. By mouthChild 12–18 years 500 mg daily in 1–2 divideddoses (in immunocompromised or HIV-positivechildren, 500 mg twice daily); therapy interruptedevery 6–12 months to reassess recurrence frequency—considerrestarting after two or morerecurrencesPrevention of cytomegalovirus disease followingsolid organ transplantation (preferablystarting within 72 hours of transplantation). By mouthChild 12–18 years 2 g 4 times daily usually for 90daysValaciclovir (Non-proprietary) ATablets, valaciclovir 500 mg, net price 10-tab pack =£19.43, 42 tab-pack = £79.04. Label: 9Valtrex c (GSK) ATablets, f/c, valaciclovir (as hydrochloride) 250 mg,net price 60-tab pack = £123.28; 500 mg, 10-tab pack= £20.59, 42-tab pack = £86.30. Label: 95.3.2.2 Cytomegalovirus infectionRecommendations for the optimum maintenance therapyof cytomegalovirus (CMV) infections and the durationof treatment are subject to rapid change.Ganciclovir is related to aciclovir but it is more activeagainst cytomegalovirus; it is also much more toxic thanaciclovir and should therefore be prescribed underspecialist supervision and only when the potential benefitoutweighs the risks. Ganciclovir is administered byintravenous infusion for the initial treatment of CMVinfection. The use of ganciclovir may also be consideredfor symptomatic congenital CMV infection. Ganciclovircauses profound myelosuppression when given withzidovudine; the two should not normally be giventogether particularly during initial ganciclovir therapy.The likelihood of ganciclovir resistance increases inpatients with a high viral load or in those who receivethe drug over a long duration; cross-resistance to cidofoviris common.Valaciclovir (section 5.3.2.1) is licensed for use inchildren over 12 years for prevention of cytomegalovirusdisease following renal transplantation.Foscarnet is also active against cytomegalovirus; it istoxic and can cause renal impairment.Cidofovir is given in combination with probenecid forCMV retinitis in AIDS patients when ganciclovir andfoscarnet are contra-indicated. Cidofovir is nephrotoxic.There is limited information on its use in children.For local treatment of CMV retinitis, see section 11.3.3.GANCICLOVIRCautions close monitoring of full blood count (severedeterioration may require correction and possiblytreatment interruption); history of cytopenia; potentialcarcinogen and teratogen; radiotherapy; ensureadequate hydration during intravenous administration;vesicant—infuse into vein with adequate flowpreferably using plastic cannula; possible risk of longtermcarcinogenic or reproductive toxicity; interactions:Appendix 1 (ganciclovir)Contra-indications hypersensitivity to valganciclovir,ganciclovir, aciclovir, or valaciclovir; abnormally lowhaemoglobin, neutrophil, or platelet counts (consultproduct literature)Renal impairment reduce dose if estimated glomerularfiltration rate less than 70 mL/minute/1.73 m 2 ;consult product literaturePregnancy avoid—teratogenic risk; ensure effectivecontraception during treatment and barrier contraceptionfor males during and for at least 90 days aftertreatmentBreast-feeding avoid—no information availableSide-effects diarrhoea, nausea, vomiting, dyspepsia,abdominal pain, constipation, flatulence, dysphagia,taste disturbance, hepatic dysfunction; dyspnoea,chest pain, cough; headache, insomnia, convulsions,dizziness, peripheral neuropathy, depression, anxiety,confusion, abnormal thinking, fatigue, weight loss,anorexia; infection, pyrexia, night sweats; anaemia,leucopenia, thrombocytopenia, pancytopenia, renalimpairment; myalgia, arthralgia; macular oedema,retinal detachment, vitreous floaters, eye pain; earpain; dermatitis, pruritus; injection-site reactions; lesscommonly mouth ulcers, pancreatitis, arrhythmias,