Induction Therapy Followed by Maintenance Therapy

Preferred Therapy

• Valganciclovir^a 900 mg PO every 12 hours for 14–21 days, then maintenance therapy with valganciclovir 900 mg PO once daily (AI), or
• Ganciclovir^a 5 mg/kg IV every 12 hours for 14–21 days, then maintenance therapy with valganciclovir 900 mg PO once daily (AI), or
• Ganciclovir^a 5 mg/kg IV every 12 hours for 14–21 days, then maintenance therapy with ganciclovir 5 mg/kg IV daily (AI)

Notes

• Many clinicians prefer the IV formulation when retinitis is more central and sight-threatening or when adequate gastrointestinal absorption is a concern; transition to oral valganciclovir can be considered when there is evidence of clinical response.
• PO valganciclovir is the preferred maintenance regimen as it is the easiest and least toxic to administer to an outpatient population, provided that gastrointestinal absorption is adequate.
   

Alternative Therapy

• Foscarnet^a 60 mg/kg IV every 8 hours or 90 mg/kg IV every 12 hours for 14–21 days, then maintenance therapy with foscarnet 90 mg/kg or 120 mg/kg IV every 24 hours (BI), or
• Cidofovir^a,b 5 mg/kg/week IV for 2 weeks, then maintenance therapy with cidofovir 5 mg/kg every other week. Administer 1 L of normal saline before and, if additional fluid load can be tolerated, administer another 1 L of normal saline after each cidofovir infusion. Administer probenecid 2 g PO 3 hours before each cidofovir dose followed by 1 g PO 2 hours after the dose, and 1 g PO 8 hours after the dose (total of 4 g) (CI).

Note: Cidofovir should be avoided in patients with sulfonamide allergy because of cross-hypersensitivity with probenecid.

 If Immediate Sight-Threatening Lesions (within 1,500 microns of the fovea or optic disc)

• Add intravitreal injections of ganciclovir (2 mg/injection) or foscarnet (2.4 mg/injection) repeated weekly during the induction period until lesion inactivity is achieved (BIII), then systemic treatment alone is considered to be adequate for maintenance therapy.

Note: Intravitreal administration of cidofovir is contraindicated, as it has been associated with uveitis and marked hypotony of the injected eye (AIII).

• Valganciclovir^a 900 mg PO every 12 hours for 14–21 days, then maintenance therapy with 900 mg once daily (AI)

• Minimum 14–21 days; duration determined by clinical response based on retinal examination

Note: Many clinicians continue induction-level treatment until retinal lesion opacity is resolved or markedly reduced, indicating virus inactivity (BIII).

• Maintenance therapy is started after induction has achieved control of retinitis. Regimens are as detailed above.

• The Panel favors the use of both corticosteroids and anti-CMV therapy for active intraocular inflammation at the onset of immune reconstitution uveitis and the use of corticosteroids for cystoid macular edemas, a late complication of immune reconstitution uveitis (CIII).
• Corticosteroids can be administered by oral, periocular, or intravitreal routes.
  • Prednisone 1 mg/kg PO daily (maximum dose of 60–80 mg/day) until clinical response, but for no longer than 1 month, followed by tapering and discontinuation over 2 to 3 months (BIII)
  • Periocular or intravitreal corticosteroid injections can be repeated after the expected duration of effect if there is evidence of incomplete clinical response and no treatment complications (BIII).