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6–28 | Clinical Manual for Management of the HIV-Infected Adult/2006
Neurologic CMV disease
The optimal treatment of neurologic disease has not
been determined. Prompt initiation of dual therapy with
intravenous ganciclovir and foscarnet may be effective in
some patients.
Monitoring CMV therapies
The medications used to treat CMV have several
important potential adverse effects, and monitoring
for these is required. Valganciclovir and ganciclovir
have been associated with bone marrow suppression,
neutropenia, anemia, thrombocytopenia, and renal
dysfunction. Foscarnet has been associated with
cytopenia, renal insufficiency, electrolyte abnormalities,
and seizures. For patients taking these medications,
perform complete blood count with differential and
check electrolytes and creatinine twice weekly during
initial therapy and once weekly during maintenance
therapy. Cidofovir has been associated with renal
insufficiency and ocular hypotony. For patients taking
cidofovir, check creatinine and blood urea nitrogen and
perform urinalysis (for proteinuria) before each dose.
Intraocular pressure must be checked at least every 6
months.
Patient Education
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Educate patients about the importance of ART in
treating CMV. Urge patients to start ART if they
have not done so already.
Patients with CMV retinitis may have to remain
on suppressive therapy for life to prevent blindness.
Patients with CMV esophagitis or enteritis usually
see improvements within 2-4 weeks of therapy.
Treatment of CMV retinitis halts progression of the
infection but does not reverse the damage already
done to the retina. Warn patients that vision will not
return to pre-CMV status.
Advise patients to report any visual deterioration
immediately. Retinal detachment or progression of
CMV must be treated immediately to avoid further
vision loss.
With gastrointestinal disease, recurrence of
symptoms warrants repeat endoscopy. Advise
patients to report any recurrence of symptoms.
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Adverse reactions to current therapies are common.
Educate patients about these and advise them to
promptly report any adverse reactions.
Help patients cope with the possibility of
therapeutic failure, and, in the case of CMV retinitis,
permanent loss of vision.
Teach patients how to maintain indwelling venous
access lines, if used. Have patients demonstrate these
techniques before discharge.
References
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Bartlett JG, Gallant JE. Medical Management of
HIV Infection, 2005-2006 Edition. Baltimore: Johns
Hopkins AIDS Service; 2005.
Drew WL, Lalezari JP. Cytomegalovirus and HIV.
In: Peiperl L, Coffey S, Volberding PA, eds. HIV
InSite Knowledge Base [textbook online]. San
Francisco: UCSF Center for HIV Information;
May 2006. Available at: http://hivinsite.ucsf.edu/
InSite?page=kb-05&doc=kb-05-03-03. Accessed
June 1, 2006.
Jacobsen MA. AIDS Related Cytomegalovirus
Gastrointestinal Disease. In: UpToDate v14.1.
Available at: http://www.uptodate.com. Accessed
June 1, 2006. [Registration required.]
Jacobsen MA. AIDS Related Cytomegalovirus
Neurologic Disease. In: UpToDate v14.1. Available at:
http://www.uptodate.com. Accessed June 1, 2006.
[Registration required.]
Jacobsen MA. AIDS Related Cytomegalovirus
Retinitis. In: UpToDate v14.1. Available at:
http://www.uptodate.com. Accessed June 1, 2006.
[Registration required.]
U.S. Public Health Service, Infectious Diseases
Society of America. Guidelines for the Treatment
of Opportunistic Infections in Adults and Adolescents
Infected with Human Immunodeficiency Virus.
MMWR Morb Mortal Wkly Rep 2004;53(RR-
15):1. Available at: http://aidsinfo.nih.gov/
Guidelines/GuidelineDetail.aspx?MenuItem=Guid
elines&Search=Off&GuidelineID=14&ClassID=4.
Accessed January 1, 2006.