Which medications in the drug class Antivirals are used in the treatment of Cytomegalovirus (CMV)?

Updated: Jul 07, 2021
  • Author: Ricardo Cedeno-Mendoza, MD; Chief Editor: Michael Stuart Bronze, MD  more...
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Answer

Antivirals

There are multiple antivirals with different mechanisms of action, these include DNA polymerase inhibitors like Ganciclovir (nucleoside analog), Cidofovir (nucleotide analog) as well as Pyrophosphate analogues such as Forcarnet. Ganciclovir is considered the treatment of choice for CMV infections

Ganciclovir (Cytovene)

Ganciclovir is a synthetic guanine derivative nucleoside analog active against CMV. It inhibits replication of herpes viruses both in vitro and in vivo. In patients with HIV infection, resistance manifests as progressive disease.

Foscarnet (Foscavir)

Foscarnet inhibits viral replication of herpesviruses (CMV, HSV-1, HSV-2) at pyrophosphate-binding site on virus-specific DNA polymerases. It is used for ganciclovir-resistant CMV retinitis and herpes simplex disease.

Cidofovir (Vistide)

Cidofovir is approved for the treatment of CMV retinitis in AIDS. It is a nucleotide analog, whose active metabolite inhibits herpes virus polymerases at concentrations that are 8- to 600-fold lower than those needed to inhibit human cellular DNA polymerases alpha, beta, and gamma. Incorporation of cidofovir into the growing viral DNA chain results in reductions in the rate of viral DNA synthesis.

Valganciclovir (Valcyte)

Valganciclovir is an L-valyl ester prodrug of ganciclovir. It is used for CMV disease prophylaxis in various solid organ transplant recipients. It inhibits the replication of human CMV in vitro and in vivo. Valganciclovir achieves serum levels comparable to those obtained with IV ganciclovir.

Letermovir (Prevymis)

Letermovir is part of a new class of non-nucleoside CMV inhibitors, the 3,4 dihydro-quinazoline-4-yl-acetic acid derivatives, and has activity in the late stages of viral replication rather than against the viral DNA polymerase like other anti-CMV therapies. It is used as prophylaxis of CMV infections. Advantages of Letermovir use include oral route and fewer side effects (no myelosupression, no nephrotoxicity).

Specifically, Letermovir inhibits the viral terminase complex at pUL56 and pUL89, which leads to compromised viral replication by preventing genomes of proper unit length and the accumulation of immature viral DNA. The approved dose of letermovir is 480 mg once daily and it is recommended as prophylaxis in CMV seropositive adult recipients of an allo-HCT between day 0 and 28 and continue until day 100 post-transplant. There are ongoing studies on Letermovir in regards to effectivity and side effects


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