Queen's School of Business Presentation
Issue link: http://invivo.uberflip.com/i/1501332
June 2023 6 CMV Management in the Post-DNA Polymerase Inhibitor Era to receive maribavir at a dose of 400 mg PO twice daily or to investigator-assigned treatment (IAT) for 8 weeks. 30 Patients were stratified by transplant type (SOT vs. allo-HCT) and viral load (high ≥91 000 IU/mL; interme diate ≥9100 to <91 000 IU/mL; low <9100 to ≥910 IU/mL). The results demonstrated a higher proportion of patients who cleared CMV on maribavir compared to IAT (55.7% vs. 23.9%) with a lower rate of treatment-emergent adverse events leading to study drug discontinuation and serious adverse events. 30 Not surprisingly, patients randomized to maribavir had higher rates of dysgeusia, but lower rates of myelosuppression and renal toxicity. In summary, maribavir is a novel CMV antiviral with a unique mechanism of action and a promising efficacy and safety profile. It should be considered for patients with refractory and resistant cases of CMV, and for those who are unable to tolerate first-line agents. Additional Agents Other therapeutic strategies have also been considered in the prevention and management of CMV, particularly in refractory and resistant cases. While an extensive review of these modalities is beyond the scope of this paper, perhaps the most promising and noteworthy treatment on the horizon is adoptive T cell therapy. In this strategy, virus-specific cytotoxic T lymphocytes (VSTs) that can rapidly generate CMV specific immunity are transferred to the patient. 31 The majority of the data for this approach has been generated among allo-HCT recipients, who can receive VSTs from their donor (if CMV seropositive), a first- degree relative, or an unrelated donor. 31,32 Challenges concerning VST manufacturing, accessibility, allogenic donor availability and matching, and in vivo persistence have delayed their widespread adoption. However, there remains significant excitement in the transplant community as clinicians are eagerly waiting for these challenges to be solved and for novel treatments to be added to our therapeutic armamentarium. Conclusion The approval of letermovir and maribavir by Health Canada has expanded treatment options for CMV prophylaxis and treatment of refractory or resistant CMV. Letermovir has already revolutionized the management of CMV in allo-HCT recipients and is expected to have a major impact on SOT recipients at risk of CMV disease in the near future. Maribavir offers a valuable therapeutic option for cases of refractory or resistant CMV and would be a viable alternative in the event of first-line agent toxicities. Clinicians should familiarize themselves with the benefits and drawbacks of these innovative antivirals, which mark a new era in the treatment of CMV and will play a crucial role in improving the care of transplant recipients and other immunosuppressed patients.