Clinical Manual for Management of the HIV-Infected ... - myCME.com

CMV retinitis
Treatment consists of 2 phases: initial therapy and
chronic maintenance therapy.
Initial therapy
Before the advent of valganciclovir, the preferred
strategy for treating CMV retinitis involved ganciclovir
intraocular implants and systemic therapy. Because
implants deliver a higher dose of drug to the retina
than any other modality (1.4 mcg/hour for up to 8
months), many experts still prefer them for patients
with sight-threatening (zone 1) disease. About half
of patients treated with implants develop disease in
the contralateral eye, and a third experience systemic
disease, within 3 months of implantation. Therefore,
patients with implants should be treated systemically
with valganciclovir (900 mg once daily; some experts
increase this to 900 mg twice daily for patients with
vision-threatening disease).
For patients with peripheral retinitis (beyond zone 1),
oral valganciclovir (see below) is the preferred treatment
because it is easy to administer and is not associated
with the surgery- or catheter-related complications seen
with intraocular treatments and intravenous therapies.
This formulation quickly converts to ganciclovir in the
body and has good bioavailability. Valganciclovir should
be used only if the patient is thought to be capable of
strict adherence. Other possible intravenous treatments
include ganciclovir, ganciclovir followed by oral
valganciclovir, foscarnet, and cidofovir. See below for
dosing recommendations.
For sight-threatening disease, treat with ganciclovir
intraocular implants plus valganciclovir 900 mg orally
once daily or twice daily.
For peripheral disease, treat with valganciclovir 900 mg
orally twice daily for 14-21 days.
Alternatives for initial therapy
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Intravenous ganciclovir 5 mg/kg every 12 hours for
14-21 days
Intravenous foscarnet 60 mg/kg every 8 hours or 90
mg/kg every 12 hours for 14-21 days
Intravenous cidofovir 5 mg/kg weekly for 2
weeks, then every other week (must be given with
probenecid [2 g orally 3 hours before, 1 g orally 2
hours after, and 1 g orally 8 hours after the cidofovir
infusion] and intravenous saline to decrease the risk
of renal toxicity)
Section 6—Disease-Specific Treatment | 6–27
Note: Valganciclovir, ganciclovir, and foscarnet require
dosage adjustment in patients with renal insufficiency.
Cidofovir is contraindicated in patients with renal
insufficiency or proteinuria.
Monitor patients closely to gauge the response to
therapy. Repeat the dilated retinal examination after
the completion of induction therapy, 1 month after
initiation of therapy, and monthly during anti-CMV
therapy. Consult with a specialist if the response to
therapy is suboptimal.
Note: Retinal detachment may occur in up to 50-60% of
patients in the first year after diagnosis. Regular followup
with an ophthalmologist is required for all patients.
Patients should report any vision loss immediately.
Chronic maintenance therapy
After initial CMV treatment, lifelong maintenance
therapy with valganciclovir or intravenous foscarnet
should be given to prevent recurrence, and the patient
needs regular reevaluation by an ophthalmologist.
Recommended dosages for maintenance therapy are as
follows:
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Valganciclovir 900 mg orally once daily
Intravenous foscarnet 90-120 mg/kg once daily
Discontinuation of maintenance therapy can be
considered for patients with inactive CMV and
sustained immune reconstitution during ART (CD4
count of >100-150 cells/µL for at least 6 months).
However, the decision should be guided by factors such
as the extent and location of the CMV lesions and
the status of the patient’s vision. An ophthalmologist
who is experienced in caring for HIV-infected
patients should be involved in making any decision to
discontinue therapy, and patients should receive regular
ophthalmologic follow-up. Maintenance therapy should
be resumed if the CD4 count drops below 100-150
cells/µL or the patient develops other signs of HIV
progression.
Gastrointestinal and pulmonary CMV disease
These infections are usually treated with intravenous
ganciclovir or foscarnet for 21-28 days unless the
patient is able to absorb oral medications, in which
case oral valganciclovir is an option (refer to the dosing
suggestions above). Some specialists recommend a
follow-up endoscopy to verify regression of lesions
before discontinuing therapy. Many experts do not
recommend maintenance therapy for gastrointestinal
CMV infections unless the disease recurs.