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12 protocols using valcyte

1

CMV Management in HSCT Recipients

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All HSCT recipients were administered with intravenous tacrolimus (Prograf, Astellas, Tokyo, Japan) or cyclosporine (Sandimmun, Novartis, Basel, Switzerland) for the prevention of GVHD. On detecting CMV viremia, we initiated intravenous infusion of ganciclovir (Cymevene, Hoffmann‐La Roche, Basel, Switzerland) according to the protocol for risk-adapted preemptive therapy for CMV disease after HSCT [23 (link)]. However, in cases of severe neutropenia, anemia, or thrombocytopenia, we administered intravenous foscarnet (Foscavir, Fresenius Kabi, Graz, Austria) instead of ganciclovir. Oral valganciclovir (Valcyte, Hoffmann‐La Roche) was used for maintenance therapy [24 (link)].
All patients with CMV retinitis initially received an intravitreal injection of ganciclovir. In cases of ganciclovir resistance, we administered intravitreal foscarnet [25 (link), 26 (link)]. Patients with reduced CMV viremia who required further systemic treatment for CMV retinitis received the necessary treatment.
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2

Valganciclovir Suppresses Neurogenesis

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Neurogenesis was suppressed by feeding the animals the orally available prodrug, valganciclovir (Valcyte, Roche), which is enzymatically converted to ganciclovir. Valcyte (7.5 mg) was given in a 0.5 g pellet of a 1:1 mixture of ground chow and peanut butter. To minimize neophobia, rats were exposed to the chow–peanut butter mixture in their home cage for 2-4 days prior to drug treatment. On drug treatment days, each rat was separated into an empty cage without bedding and individual Valcyte pellets were placed on the wall of the cage and monitored for feeding activity to ensure consistent dosing. Once the animal consumed the drug pellet the animal was moved back to the housing chamber. The entire feeding procedure lasted between 4-7 minutes and care was taken to reduce any stressful experience. Valcyte treatment (1x/d) was initiated during week 6 of CIE and was continued until the day of euthanasia. All CIE animals consumed the vehicle or Valcyte chow/peanut butter pellet (+/− Valcyte; males: n = 11 Valcyte, n = 14 Valcyte+; females, n = 15 Valcyte, n = 10 Valcyte+).
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3

Valganciclovir and Ganciclovir Dosing Based on eGFR

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Valganciclovir [oral—Valganciclovir Accord (Accord Pharmaceuticals, Ahmedabad, India) 450 mg film-coated tablets; Valcyte (Roche, Basel, Switzerland) powder for oral solution 50 mg/mL] and ganciclovir [intravenous—Ganciclovir (Sandoz, Basel, Switzerland) 500 mg powder for solution for infusion] were administered according to the estimated glomerular filtration rate (eGFR; calculated with CKD-EPI). Regardless of eGFR, every patient received a first day full dose 900 mg twice daily (orally) or 5 mg/kg twice daily (intravenously). Therapeutic dosing in different eGFR ranges was as follows for oral dosing: 40–59 mL/min/1.73 m2, 450 mg twice daily; 25–39 mL/min/1.73 m2, 450 mg once daily; and 10–24 mL/min/1.73 m2, 450 mg every other day. Therapeutic dosing in different eGFR ranges was as follows for intravenous dosing: 50–69 mL/min/1.73 m2, 2.5 mg/kg twice daily; 25–49 mL/min/1.73 m2, 2.5 mg/kg once daily; and 10–24 mL/min/1.73 m2, 1.25 mg/kg once daily. If eGFR was <10 mL/min/1.73 m2 the dose was determined by the attending pharmacist and virologist, based on early TDM.
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4

Ganciclovir/Valganciclovir Therapy for EBV/CMV Seropositivity

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Patients with Epstein-Barr virus (EBV) or cytomegalovirus (CMV) donor-seropositive/recipient-seronegative received 900 mg each day for 14 weeks of oral ganciclovir (Cytovene®, Hoffman-La Roche Ltd., ON, Canada) or valgancyclovir (Valcyte®, Hoffman-La Roche Ltd, ON, Canada) therapy. Patients who were CMV donor seropositive/recipient seropositive or donor seronegative/recipient seropositive received 2 weeks of 900 mg twice per day of oral ganciclovir or valganciclovir therapy.
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5

Kidney Transplant Prophylactic Regimens

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Standard prophylaxes consisted of 800/160 mg trimethoprim/sulfamethoxazole (Cotrim forte®, Hexal) administered three times weekly for 6 months and topical amphotericine B (Ampho-Moronal®, Bristol-Myers Squibb) in the postoperative period. Additionally, all patients with a major risk profile for cytomegalovirus (CMV) (donor CMV IgG +/recipient CMV IgG -) received gancyclovir (Cymeven®, Roche) i.v. during the early postoperative phase followed by oral administration of valganciclovir (Valcyte®, Roche) for a minimum of 3 months adjusted to kidney function. These prophylactic regimens were adopted from the local routine practice at the time of kidney transplantation at the Hannover Medical School.
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6

Immunosuppressive Protocol for Organ Transplant

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Standard immunosuppression included induction therapy with a single dose of 8 mg per kg bodyweight antithymocyte globulin (ATG) (ATG‐Fresenius®; Fresenius Biotech, Gräfelfing, Germany); tacrolimus (Prograf®; Astellas Pharma, Vienna, Austria) with trough levels of 12–15 ng/ml for the first 3 months, aiming at 3–5 ng/ml at 2 years after transplantation; mycophenolate mofetil (CellCept®; Roche Austria, Vienna, Austria) at a dose of 1 g twice daily, or enteric coated mycofenolic acid (Myfortic®; Novartis Austria, Vienna, Austria) at a dose of 720 mg twice daily; and a steroid taper with an attempt to wean steroids at 1 year.
Perioperative antimicrobial prophylaxis consisted of tazobactam/piperacillin (Tazonam®; Pfizer Austria, Vienna, Austria) and ciprofloxacin (Ciproxin®; Bayer Austria, Vienna, Austria) for 3 days. Fluconazole (Diflucan®; Pfizer Austria) was given for 7 days. In the event of a CMV mismatch (D+/R–), antiviral prophylaxis consisted of valganciclovir (Valcyte®; Roche Austria) for 3 months.
Octreotide acetate (Sandostatin®; Novartis Austria) was administered for 7 days. Blood glucose levels were kept below 120 mg/dl in the ICU. In the general ward, levels exceeding 150 mg/dl were treated with subcutaneous insulin. Grafts were monitored closely by daily ultrasound examination17.
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7

CMV Prophylaxis in Kidney Transplant

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All patients received prophylaxis with trimethoprim/sulfamethoxazole (160/800 mg three times per week) against pneumocystis jirovecii infection for 6 months. The CMV prevention strategy at our center has been described previously (15 (link)). Briefly, high-risk patients (D+/R–) received prophylaxis with oral valganciclovir (Valcyte, Roche) 450 mg twice daily adjusted for renal function. Intermediate-risk patients (R+) received prophylaxis with valganciclovir, if they had an induction therapy with ATG or were ABO-incompatible. All other intermediate-risk patients were managed by regular monitoring and deferred therapy. Low-risk patients (D–/R–) received no prophylaxis and had no regular screening. Prophylaxis was given for a minimum of 3 months and prolonged, if immunosuppression was still considered as high (e.g., recent rejection therapy).
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8

Prophylaxis against Pneumocystis and CMV

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All patients received prophylaxis with trimethoprim/sulfamethoxazole (160 mg/800 mg three times per week) against pneumocystis jirovecii infection for six months.
The CMV prevention strategy at our center has been described previously [16 (link)]. Briefly, high‐risk patients (D+/R‐) received prophylaxis with oral valganciclovir (Valcyte, Roche) 450 mg twice daily adjusted for renal function. Intermediate‐risk patients (R+) received prophylaxis with valganciclovir if they had an induction therapy with ATG or were ABO‐incompatible. All other intermediate‐risk patients were managed by regular monitoring and deferred therapy. Low‐risk patients (D‐/R‐) received no prophylaxis and had no regular screening. Prophylaxis was given for a minimum of 3 months and prolonged if immunosuppression was still considered as high (e.g., recent rejection therapy).
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9

Antiviral Treatment Protocols for Congenital CMV

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During the study period, antiviral treatment using 1 of 2 protocols was offered to all children with a symptomatic disease as described, including any cyst finding, Protocol 1: intravenous ganciclovir 5 mg/kg/dose in 2 daily doses for 6 weeks followed by oral valganciclovir (Valcyte, Hoffmann-La Roche Ltd, Basel, Switzerland) 17 mg/kg/dose in 2 daily doses for another 6 weeks and then 1 daily dose until age 1; or protocol 2: oral valganciclovir 17 mg/kg/dose in 2 daily doses for 12 weeks, then 1 daily dose until age 1, as previously described.
As mentioned, all cCMV neonates in our clinic underwent a BERA examination within the first 4 weeks of life. Furthermore, in our clinic, follow-up hearing assessments are performed via a BERA examination, in children ≤2 years old, and a behavioral hearing test, in children >2 years of age, every 4-6 months until the age of 5.
The study was approved by the institutional Helsinki committee.
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10

Kidney Transplant CMV Prophylaxis

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Patient's characteristics A total of 24 CMV seropositive patients who received kidney transplantation from LD between with panel reactive antibody (PRA)<20 % received induction with basiliximab (Simulect®, Novartis, Switzerland) and 12 patients with PRA>20 % received induction therapy based on rATG (Thymoglobuline®, Genzyme Corporation, Cambridge) with a mean cumulative dose 5 mg/kg within the first week after transplantation. All CMV seropositive patients treated with rATG received valgancyclovir prophylaxis (Valcyte®, Roche, Czech Republic) for 100 days.
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