eCase - Optimal Strategy for CMV Prevention in HCT

CE / CME

Reducing the Burden of Cytomegalovirus in HCT: Optimal Strategy for Prevention

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Nurse Practitioners: 1.00 Nursing contact hours, includes 1.00 hour of pharmacotherapy credit

Released: July 21, 2023

Expiration: July 20, 2024

Roy F. Chemaly, MD, MPH

CME/CE Information

Activity

Progress

Course Completed

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Poll 1 Presurvey Overview of CMV Infection in HCT Types and Consequences of CMV Disease After HCT Risk Factors for CMV Development After HCT Timing and CMV Risk PET for CMV Managing Side Effects and Toxicity of Antivirals in PET Antivirals for CMV Primary Prophylaxis Managing Aspects of Prophylaxis With Letermovir Decision-making: PET vs Prophylaxis Pros and Cons of Prophylaxis Strategy On the Horizon References Assessment

Decision-making: PET vs Prophylaxis

According to guidelines from ASTCT, PET and prophylaxis are complementary approaches to CMV disease prevention, and all centers should be equipped for both.⁷ Among the benefits of a PET strategy are the potential to reduce unnecessary treatment with antivirals and associated toxicity and resistance development.^7,20 Resistance development is a concern because several antivirals share major resistance mutations (eg, UL54), including first-line choices ganciclovir and valganciclovir, as well as foscarnet and cidofovir. Newer agents, including maribavir and letermovir, are associated with different mutations, limiting cross-resistance.²¹

PET strategies also have a long history with a large body of evidence, providing confidence in their use. However, most factors favor a prophylaxis strategy with letermovir if available. Among the caveats with PET strategies is the demonstrated effect of even minor CMV reactivation in the 100 days following HCT on development of end-organ disease, risk for acute or chronic GVHD and invasive fungal infections, and poorer transplant outcomes including mortality.^6,8,9

There is also the chance that rapid viral load doubling time may outpace the antiviral effect of PET intervention in some patients.¹⁰ In addition, while a PET strategy may reduce risk for early-onset CMV disease, patients remain at risk for late-onset and development of refractory or resistant CMV infection.⁶ Finally, logistic and cost difficulties can hamper effective PET strategies, including the need for ongoing monitoring for 100+ days.^10,20

Expert Insights From Dr Chemaly: My Experiences with PET vs Prophylaxis: What It Involves, Impact on Patients, and Toxicities

Which of these factors must be considered when providing primary prophylaxis with letermovir?

A.
Accelerated CMV-specific immune reconstitution
B.
Age older than 65 years
C.
Increased rates of myelotoxicity
D.
Need for second antiviral for prevention of other herpesviruses

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