Pescovitz Mark D
Organ Transplant Program, Indiana University Medical Center, Indianapolis, IN, USA.
Am J Health Syst Pharm. 2003 Dec 1;60(23 Suppl 8):S17-21. doi: 10.1093/ajhp/60.suppl_8.S17.
Four types of therapeutic strategies for managing cytomegalovirus (CMV) in solid organ transplant recipients, the mechanisms of action and efficacy of drugs used for prophylaxis, and the criteria for evaluating drugs for inclusion in a formulary are described. Universal and selective prophylaxis are simple to implement and effective for CMV prophylaxis, but they are costly and patient nonadherence and viral resistance can develop. Preemptive therapy may cause less resistance and cost less, but it is more complex and associated with a higher incidence of infection, which may have no effect on secondary effects from CMV infection, and higher recurrence of disease than prophylactic therapy. Treatment of active disease may be less costly for the drug than other approaches, but intravenous access is required and the rates of infection recurrence and mortality are higher compared with prophylaxis and preemptive therapy. Criteria for deciding which CMV prophylactic drugs to include in a formulary include efficacy, safety, convenience, and cost. CMV immune globulin i.v. is costly and exhibits reduced efficacy when used alone in patients at high risk for CMV disease. Intravenous ganciclovir is effective, but it is costly because of infusion costs. Intravenous drug therapies are inconvenient and associated with a risk of bacterial and fungal infection. Oral acyclovir is safe to use and inexpensive (since a genetic exists), but it has poor efficacy and is inconvenient because of the need for four large daily doses. Valacyclovir is more convenient and with similar safety and probably better efficacy than acyclovir, but it is more costly. Oral ganciclovir and oral valganciclovir have similar safety and costs, with greater efficacy than acyclovir. The single daily dose and lack of resistance to valganciclovir are advantages over oral ganciclovir, which requires three daily doses and can result in the development of resistance.
本文描述了实体器官移植受者中管理巨细胞病毒（CMV）的四种治疗策略、预防性用药的作用机制和疗效，以及评估药物纳入处方集的标准。普遍预防和选择性预防易于实施且对CMV预防有效，但成本高昂，患者可能不依从且会产生病毒耐药性。抢先治疗可能产生的耐药性较少且成本较低，但更为复杂，感染发生率较高，可能对CMV感染的继发效应无效，且疾病复发率高于预防性治疗。活动性疾病的治疗对于药物来说可能比其他方法成本更低，但需要静脉通路，与预防性治疗和抢先治疗相比，感染复发率和死亡率更高。决定将哪些CMV预防性药物纳入处方集的标准包括疗效、安全性、便利性和成本。静脉注射CMV免疫球蛋白成本高昂，在CMV疾病高危患者中单独使用时疗效会降低。静脉注射更昔洛韦有效，但由于输液成本，费用较高。静脉用药治疗不方便，且有细菌和真菌感染的风险。口服阿昔洛韦使用安全且价格便宜（因为有仿制药），但疗效较差，且由于需要每日服用四大剂量而不方便。伐昔洛韦更方便，安全性相似，疗效可能比阿昔洛韦更好，但成本更高。口服更昔洛韦和口服缬更昔洛韦安全性和成本相似，疗效优于阿昔洛韦。缬更昔洛韦每日单剂量且无耐药性，这比口服更昔洛韦更具优势，口服更昔洛韦需要每日服用三次剂量，且可能会产生耐药性。
