In this episode, I’ll discuss whether oral valganciclovir is really as good as IV ganciclovir for the treatment of CMV infection.
Shout out to “Pulmonary Ashley” for inspiring this episode!
When considering therapy to treat a CMV infection, multiple references suggest that oral therapy with valganciclovir is noninferior or even preferred to IV therapy with ganciclovir. For example, Johns Hopkins ABX Guide states: “Oral valganciclovir is shown to be non-inferior to IV ganciclovir in those with non life-threatening disease” and The Third International Consensus Guidelines on the Management of Cytomegalovirus in Solid-organ Transplantation state “Although both may be used for non–life-threatening CMV disease, VGCV is preferred when feasible due to its oral formulation which may prevent or reduce hospital stays and minimize the infectious and vascular complications associated with intravenous therapy.”
This advice may seem counter-intuitive as typically IV therapy is preferred for serious infections, especially in the immunocompromised. However the data these recommendations are based on is extensive and goes back several years.
The VICTOR trial was a randomized international study published in 2007 and showed that success rates for viremia eradication and treatment success were no different between oral or IV therapy at days 21 and 49.
And a meta-analysis from 2014 that included 19 studies concluded:
Valganciclovir as an alternative to ganciclovir can be used with equal efficacy in prevention and treatment of CMV disease in solid organ transplant receipients.
The side-effect profile of the two medications is similar, and the equal efficacy probably comes from the fact that the AUC after a 900 mg oral valganciclovir dose is comparable to that of a 5mg/kg IV dose of ganciclovir.
Furthermore, the recommendation to use IV therapy in the setting of a life-threatening infection does not appear to be based on actual trial data showing superiority of ganciclovir in this setting. Rather it is an empiric recommendation because often in a life-threatening infection there is a risk of malabsorption of any medication from the GI tract and this risk, however small, is not acceptable in a life-threatening infection when an IV treatment is so readily available.
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