1
|
Obermaier B, Braun C, Hensen L, Ahmad O, Faul C, Lang P, Bethge W, Lengerke C, Vogel W. Adenovirus- and cytomegalovirus-specific adoptive T-cell therapy in the context of hematologic cell transplan or HIV infection - A single-center experience. Transpl Infect Dis 2024:e14296. [PMID: 38830809 DOI: 10.1111/tid.14296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 04/17/2024] [Accepted: 05/05/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Reactivation of viral infections, in particular cytomegalovirus (CMV) and adenovirus (ADV), cause morbidity and non-relapse-mortality in states of immune deficiency, especially after allogeneic hematopoietic cell transplantation (allo-HCT). Against the background of few available pharmacologic antiviral agents, limited by toxicities and resistance, adoptive transfer of virus-specific T-cells (VST) is a promising therapeutic approach. METHODS We conducted a single-center retrospective analysis of adult patients treated with ADV- or CMV-specific T-cells in 2012-2022. Information was retrieved by review of electronic health records. Primary outcome was a response to VST by decreasing viral load or clinical improvement. Secondary outcomes included overall survival and safety of VST infusion, in particular association with graft-versus-host disease (GVHD). RESULTS Ten patients were included, of whom four were treated for ADV, five for CMV, and one for ADV-CMV-coinfection. Cells were derived from stem cell donors (6/10) or third-party donors (4/10). Response criteria were met by six of 10 patients (4/4 ADV, 2/5 CMV, and 0/1 ADV-CMV). Overall survival was 40%. No infusion related adverse events were documented. Aggravation of GVHD after adoptive immunotherapy was observed in two cases, however in temporal association with a conventional donor lymphocyte infusion and a stem cell boost, respectively. CONCLUSION In this cohort, CMV- and ADV-specific T-cell therapy appear to be safe and effective. We describe the first reported case of virus-specific T-cell therapy for CMV reactivation not associated with transplantation but with advanced HIV infection. This encourages further evaluation of adoptive immunotherapy beyond the context of allo-HCT.
Collapse
Affiliation(s)
- Benedikt Obermaier
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Christiane Braun
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Luca Hensen
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Osama Ahmad
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Christoph Faul
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Peter Lang
- Department of Pediatric Hematology and Oncology, University Children's Hospital Tuebingen, Tuebingen, Germany
| | - Wolfgang Bethge
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Claudia Lengerke
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| | - Wichard Vogel
- Department of Hematology, Oncology, Clinical Immunology, and Rheumatology, Center for Internal Medicine, University Hospital Tuebingen, Tuebingen, Germany
| |
Collapse
|
2
|
Song E. Case Report: Approaches for managing resistant cytomegalovirus in pediatric allogeneic hematopoietic cell transplantation recipients. Front Pediatr 2024; 12:1394006. [PMID: 38884102 PMCID: PMC11177687 DOI: 10.3389/fped.2024.1394006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/26/2024] [Indexed: 06/18/2024] Open
Abstract
The instructional case is a pediatric haploidentical TCRαβ+/CD19+ depleted allogeneic hematopoietic cell transplantation recipient who developed early onset CMV infection, which was complicated by resistant CMV (both UL97 and UL54) and successfully managed with maribavir and haploidentical CMV-specific T lymphocytes. Novel approaches to resistant CMV infection are reviewed and effective utilization of recent advances in diagnosis and management of resistant CMV in pediatric HCT are highlighted.
Collapse
Affiliation(s)
- Eunkyung Song
- Department of Pediatrics, The Ohio State University, Columbus, OH, United States
- Division of Infectious Diseases & Host Defense, Nationwide Children’s Hospital, Columbus, OH, United States
| |
Collapse
|
3
|
Camargo JF, Natori Y. The Many Colors of the AURORA: Trial Design Issues Worth Noting. Clin Infect Dis 2024:ciae113. [PMID: 38571315 DOI: 10.1093/cid/ciae113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
- Jose F Camargo
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Yoichiro Natori
- Division of Infectious Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| |
Collapse
|
4
|
Papanicolaou GA, Avery RK, Cordonnier C, Duarte RF, Haider S, Maertens J, Peggs KS, Solano C, Young JAH, Fournier M, Murray RA, Wu J, Bo T, Winston DJ. AURORA: A New Dawn. Clin Infect Dis 2024:ciae114. [PMID: 38571316 DOI: 10.1093/cid/ciae114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024] Open
Affiliation(s)
| | | | - Catherine Cordonnier
- Haematology Department, Henri Mondor Hôpital, Assistance Publique-Hopitaux de Paris, and Université Paris-Est-Créteil, Créteil, France
| | - Rafael F Duarte
- Department of Haematology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Shariq Haider
- Juravinski Hospital and Cancer Center, Hamilton Health Sciences Corporation, Hamilton, Ontario, Canada
| | - Johan Maertens
- Haematology Department, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Karl S Peggs
- Department of Haematology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Carlos Solano
- Hematology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain
| | | | - Martha Fournier
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Rose Ann Murray
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Jingyang Wu
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Tien Bo
- Takeda Development Center Americas, Inc, Lexington, Massachusetts, USA
| | - Drew J Winston
- Department of Medicine, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| |
Collapse
|
5
|
Kleiboeker HL, Prom A, Paplaczyk K. Development of cytomegalovirus resistant to maribavir: real world, real problem? Transpl Infect Dis 2024; 26:e14259. [PMID: 38430481 DOI: 10.1111/tid.14259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 03/03/2024]
Affiliation(s)
- Hanna L Kleiboeker
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Alyson Prom
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| | - Krista Paplaczyk
- Department of Pharmacy, Northwestern Memorial Hospital, Chicago, Illinois, USA
| |
Collapse
|
6
|
Schultz BG, Kotton CN, Jutlla G, Ressa R, de Lacey T, Chowdhury E, Bo T, Fenu E, Gelone DK, Poirrier JE, Amorosi SL. Cost-effectiveness of maribavir versus conventional antiviral therapies for post-transplant refractory cytomegalovirus infection with or without genotypic resistance: A US perspective. J Med Virol 2024; 96:e29609. [PMID: 38647051 DOI: 10.1002/jmv.29609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 03/20/2024] [Accepted: 04/05/2024] [Indexed: 04/25/2024]
Abstract
This study evaluated the cost-effectiveness of maribavir versus investigator-assigned therapy (IAT; valganciclovir/ganciclovir, foscarnet, or cidofovir) for post-transplant refractory cytomegalovirus (CMV) infection with or without resistance. A two-stage Markov model was designed using data from the SOLSTICE trial (NCT02931539), real-world multinational observational studies, and published literature. Stage 1 (0-78 weeks) comprised clinically significant CMV (csCMV), non-clinically significant CMV (n-csCMV), and dead states; stage 2 (78 weeks-lifetime) comprised alive and dead states. Total costs (2022 USD) and quality-adjusted life years (QALYs) were estimated for the maribavir and IAT cohorts. An incremental cost-effectiveness ratio was calculated to determine cost-effectiveness against a willingness-to-pay threshold of $100 000/QALY. Compared with IAT, maribavir had lower costs ($139 751 vs $147 949) and greater QALYs (6.04 vs 5.83), making it cost-saving and more cost-effective. Maribavir had higher acquisition costs compared with IAT ($80 531 vs $65 285), but lower costs associated with administration/monitoring ($16 493 vs $27 563), adverse events (AEs) ($11 055 vs $16 114), hospitalization ($27 157 vs $33 905), and graft loss ($4516 vs $5081), thus making treatment with maribavir cost-saving. Maribavir-treated patients spent more time without CMV compared with IAT-treated patients (0.85 years vs 0.68 years), leading to lower retreatment costs for maribavir (cost savings: -$42 970.80). Compared with IAT, maribavir was more cost-effective for transplant recipients with refractory CMV, owing to better clinical efficacy and avoidance of high costs associated with administration, monitoring, AEs, and hospitalizations. These results can inform healthcare decision-makers on the most effective use of their resources for post-transplant refractory CMV treatment.
Collapse
Affiliation(s)
- Bob G Schultz
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Camille N Kotton
- Infectious Diseases Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ginita Jutlla
- Parexel, Health Economics and Outcomes Research Modeling, London, UK
| | - Riccardo Ressa
- Parexel, Health Economics and Outcomes Research Modeling, London, UK
| | - Tam de Lacey
- Parexel, Health Economics and Outcomes Research Modeling, London, UK
| | - Emtiyaz Chowdhury
- Parexel, Health Economics and Outcomes Research Modeling, London, UK
| | - Tien Bo
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| | | | - Daniele K Gelone
- Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | | | - Stacey L Amorosi
- Takeda Development Center Americas, Inc., Lexington, Massachusetts, USA
| |
Collapse
|
7
|
Monday LM, Keri V, Chandrasekar PH. Advances in pharmacotherapies for cytomegalovirus infection: what is the current state of play? Expert Opin Pharmacother 2024; 25:685-694. [PMID: 38717943 DOI: 10.1080/14656566.2024.2353627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Accepted: 05/07/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION Cytomegalovirus (CMV) remains a serious opportunistic infection in hematopoietic cell transplant (HCT) and solid-organ transplant (SOT) recipients. Traditional anti-CMV drugs are limited by toxicities and the development of resistance. Letermovir and maribavir are newly approved antivirals for the prevention and treatment of CMV. AREAS COVERED Prior reviews have discussed use of letermovir for prevention of CMV after HCT and maribavir for resistant or refractory (R/R) CMV post HCT or SOT. Subsequent data have expanded their use including letermovir for primary CMV prophylaxis in high-risk renal transplant recipients and new recommendations for extending prophylaxis through day + 200 in certain HCT patients. Data on the use of maribavir for first asymptomatic CMV infection post-HCT has also been published. This review compares the pharmacology of anti-CMV agents and discusses the updated literature of these new drugs in the prevention and treatment of CMV. EXPERT OPINION Letermovir and maribavir are much needed tools that spare toxicities of ganciclovir, foscarnet, and cidofovir. High cost is a challenge preventing their integration into clinical practice in resource-limited countries. Transplant centers need to exercise restraint in overuse to avoid resistance, particularly in the setting of high viral loads.
Collapse
Affiliation(s)
- Lea M Monday
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
| | - Vishakh Keri
- Division of Infectious Diseases, Department of Medicine, Wayne State University, Detroit, MI, USA
| | | |
Collapse
|
8
|
Schultz BG, Bullano M, Paratane D, Rajagopalan K. Cytomegalovirus related hospitalization costs among hematopoietic stem cell and solid organ transplant recipients treated with maribavir versus investigator-assigned therapy: A US-based study. Transpl Infect Dis 2024; 26:e14216. [PMID: 38221739 DOI: 10.1111/tid.14216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 10/19/2023] [Accepted: 12/02/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND Cytomegalovirus (CMV) infections among hematopoietic stem cell transplant (HSCT) and solid organ transplant (SOT) recipients impose a significant health care resource utilization (HCRU)-related economic burden. Maribavir (MBV), a novel anti-viral therapy (AVT), approved by the United States Food and Drug Administration for post-transplant CMV infections refractory (with/without resistance) to conventional AVTs has demonstrated lower hospital length of stay (LOS) versus investigator-assigned therapy (IAT; valgancilovir, ganciclovir, foscarnet, or cidofovir) in a phase 3 trial (SOLSTICE). This study estimated the HCRU costs of MBV versus IAT. METHODS An economic model was developed to estimate HCRU costs for patients treated with MBV or IAT. Mean per-patient-per-year (PPPY) HCRU costs were calculated using (i) annualized mean hospital LOS in SOLSTICE, and (ii) CMV-related direct costs from published literature. Probabilistic sensitivity analysis with Monte-Carlo simulations assessed model robustness. RESULTS Of 352 randomized patients receiving MBV (n = 235) or IAT (n = 117) for 8 weeks in SOLSTICE, 40% had HSCT and 60% had SOT. Mean overall PPPY HCRU costs of overall hospital-LOS were $67,205 (95% confidence interval [CI]: $33,767, $231,275) versus $145,501 (95% CI: $62,064, $589,505) for MBV and IAT groups, respectively. Mean PPPY ICU and non-ICU stay costs were: $32,231 (95% CI: $5,248, $184,524) versus $45,307 (95% CI: $3,957, $481,740) for MBV and IAT groups, and $82,237 (95% CI: $40,397, $156,945) MBV versus $228,329 (95% CI: $94,442, $517,476) for MBV and IAT groups, respectively. MBV demonstrated cost savings in over 99.99% of simulations. CONCLUSIONS This analysis suggests that Mean PPPY HCRU costs were 29%-64% lower with MBV versus other-AVTs.
Collapse
Affiliation(s)
- Bob G Schultz
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Michael Bullano
- US Medical Affairs Outcomes Research, Takeda Pharmaceuticals U.S.A., Inc., Lexington, Massachusetts, USA
| | - Deepika Paratane
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
| | - Krithika Rajagopalan
- Health Economics and Outcomes Research, Anlitiks, Inc., Windermere, Florida, USA
| |
Collapse
|
9
|
Chou S, Watanabe J. Ganciclovir and maribavir cross-resistance revisited: Relative drug susceptibilities of canonical cytomegalovirus mutants. Antiviral Res 2024; 222:105792. [PMID: 38163624 PMCID: PMC10922325 DOI: 10.1016/j.antiviral.2023.105792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/03/2024]
Abstract
Therapeutic use of maribavir for human cytomegalovirus infection has renewed attention to the extent of cross-resistance with ganciclovir as the existing standard therapy. Each drug selects in vivo for a characteristic set of resistance mutations in the viral UL97 kinase gene. To improve the calibration of relative susceptibilities to each drug, genetic variants at relevant UL97 codons were extensively phenotyped using the same baseline viral clone, cell culture conditions and growth readout. Ganciclovir-selected mutations at codons 460, 520, 592, 594, 595 and 603 conferred 2.8-fold (C603Y) to 12-fold (M460I) increases in ganciclovir 50% inhibitory concentrations (EC50) over wild type baseline, while conferring maribavir EC50 fold changes ranging from 0.21-fold (M460I) to 1.9-fold (A594V). Maribavir-selected mutations at codons 409, 411 and 480 conferred maribavir EC50 fold changes ranging from 17 (H411Y) to 210 (C480F), while conferring ganciclovir EC50 fold changes ranging from 0.7 (H411Y) to 2.3 (C480F). The P-loop substitution F342Y, selected by either drug, is confirmed to confer 4.7-fold and 6-fold increases in maribavir and ganciclovir EC50s respectively, and suggests this part of the ATP-binding domain of UL97 to be involved in moderate resistance to both drugs. The maribavir hypersensitivity of M460I and M460V may be advantageous.
Collapse
Affiliation(s)
- Sunwen Chou
- Department of Veterans Affairs Medical Center, Portland, OR, USA; Division of Infectious Diseases, Oregon Health and Science University, USA.
| | - Justin Watanabe
- Department of Veterans Affairs Medical Center, Portland, OR, USA
| |
Collapse
|
10
|
Pearce H, Montgomery EK, Sheerin N, Ellam H. A Novel Case of CMV Resistance to Valganciclovir and Maribavir in a Renal Transplant Patient. Transpl Int 2024; 37:11985. [PMID: 38314399 PMCID: PMC10834638 DOI: 10.3389/ti.2024.11985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 01/10/2024] [Indexed: 02/06/2024]
Affiliation(s)
- Helen Pearce
- Newcastle Hospitals Trust, Newcastle upon Tyne, United Kingdom
| | - Emma K. Montgomery
- Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Neil Sheerin
- Renal Services, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
- Immunity and Inflammation Theme, Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helena Ellam
- Department of Virology, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| |
Collapse
|
11
|
Piret J, Boivin G. Management of Cytomegalovirus Infections in the Era of the Novel Antiviral Players, Letermovir and Maribavir. Infect Dis Rep 2024; 16:65-82. [PMID: 38247977 PMCID: PMC10801527 DOI: 10.3390/idr16010005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 01/08/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
Cytomegalovirus (CMV) infections may increase morbidity and mortality in immunocompromised patients. Until recently, standard antiviral drugs against CMV were limited to viral DNA polymerase inhibitors (val)ganciclovir, foscarnet and cidofovir with a risk for cross-resistance. These drugs may also cause serious side effects. This narrative review provides an update on new antiviral agents that were approved for the prevention and treatment of CMV infections in transplant recipients. Letermovir was approved in 2017 for CMV prophylaxis in CMV-seropositive adults who received an allogeneic hematopoietic stem cell transplant. Maribavir followed four years later, with an indication in the treatment of adult and pediatric transplant patients with refractory/resistant CMV disease. The target of letermovir is the CMV terminase complex (constituted of pUL56, pUL89 and pUL51 subunits). Letermovir prevents the cleavage of viral DNA and its packaging into capsids. Maribavir is a pUL97 kinase inhibitor, which interferes with the assembly of capsids and the egress of virions from the nucleus. Both drugs have activity against most CMV strains resistant to standard drugs and exhibit favorable safety profiles. However, high-level resistance mutations may arise more rapidly in the UL56 gene under letermovir than low-grade resistance mutations. Some mutations emerging in the UL97 gene under maribavir can be cross-resistant with ganciclovir. Thus, letermovir and maribavir now extend the drug arsenal available for the management of CMV infections and their respective niches are currently defined.
Collapse
Affiliation(s)
| | - Guy Boivin
- Centre de Recherche en Infectiologie, CHU de Québec-Université Laval, Quebec City, QC G1V 4G2, Canada;
| |
Collapse
|
12
|
Sun K, Fournier M, Sundberg AK, Song IH. Maribavir: Mechanism of action, clinical, and translational science. Clin Transl Sci 2024; 17:e13696. [PMID: 38071422 PMCID: PMC10801391 DOI: 10.1111/cts.13696] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/20/2023] [Accepted: 11/21/2023] [Indexed: 01/24/2024] Open
Abstract
Maribavir is an oral benzimidazole riboside for treatment of post-transplant cytomegalovirus (CMV) infection/disease that is refractory to prior antiviral treatment (with or without resistance). Through competitive inhibition of adenosine triphosphate, maribavir prevents the phosphorylation actions of UL97 to inhibit CMV DNA replication, encapsidation, and nuclear egress. Maribavir is active against CMV strains with viral DNA polymerase mutations that confer resistance to other CMV antivirals. After oral administration, maribavir is rapidly and highly absorbed (fraction absorbed >90%). The approved dose of 400 mg twice daily (b.i.d.) achieves a steady-state area under the curve per dosing interval of 128 h*μg/mL and trough concentration of 4.90 μg/mL (13.0 μM). Maribavir is highly bound to human plasma proteins (98%) with a small apparent volume of distribution of 27.3 L. Maribavir is primarily cleared by hepatic CYP3A4 metabolism; its major metabolite, VP44669 (pharmacologically inactive), is excreted in the urine and feces. There is no clinically relevant impact on maribavir pharmacokinetics by age, sex, race/ethnicity, body weight, transplant type, or hepatic/renal impairment status. In phase II dose-ranging studies, maribavir showed similar rates of CMV viral clearance across 400, 800, or 1200 mg b.i.d. groups, ranging from 62.5-70% in study 202 (NCT01611974) and 74-83% in study 203 (EudraCT 2010-024247-32). In the phase III SOLSTICE trial (NCT02931539), maribavir 400 mg b.i.d. demonstrated superior CMV viremia clearance at week 8 versus investigator-assigned treatments, with lower treatment discontinuation rates. Dysgeusia, nausea, vomiting, and diarrhea were commonly experienced adverse events among patients treated with maribavir in clinical trials.
Collapse
Affiliation(s)
- Kefeng Sun
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Martha Fournier
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Aimee K. Sundberg
- Clinical Sciences, Rare Genetics & Hematology Therapeutic Area UnitTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| | - Ivy H. Song
- Quantitative Clinical PharmacologyTakeda Development Center Americas, Inc.LexingtonMassachusettsUSA
| |
Collapse
|
13
|
Gourin C, Alain S, Hantz S. Anti-CMV therapy, what next? A systematic review. Front Microbiol 2023; 14:1321116. [PMID: 38053548 PMCID: PMC10694278 DOI: 10.3389/fmicb.2023.1321116] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 11/06/2023] [Indexed: 12/07/2023] Open
Abstract
Human cytomegalovirus (HCMV) is one of the main causes of serious complications in immunocompromised patients and after congenital infection. There are currently drugs available to treat HCMV infection, targeting viral polymerase, whose use is complicated by toxicity and the emergence of resistance. Maribavir and letermovir are the latest antivirals to have been developed with other targets. The approval of letermovir represents an important innovation for CMV prevention in hematopoietic stem cell transplant recipients, whereas maribavir allowed improving the management of refractory or resistant infections in transplant recipients. However, in case of multidrug resistance or for the prevention and treatment of congenital CMV infection, finding new antivirals or molecules able to inhibit CMV replication with the lowest toxicity remains a critical need. This review presents a range of molecules known to be effective against HCMV. Molecules with a direct action against HCMV include brincidofovir, cyclopropavir and anti-terminase benzimidazole analogs. Artemisinin derivatives, quercetin and baicalein, and anti-cyclooxygenase-2 are derived from natural molecules and are generally used for different indications. Although they have demonstrated indirect anti-CMV activity, few clinical studies were performed with these compounds. Immunomodulating molecules such as leflunomide and everolimus have also demonstrated indirect antiviral activity against HCMV and could be an interesting complement to antiviral therapy. The efficacy of anti-CMV immunoglobulins are discussed in CMV congenital infection and in association with direct antiviral therapy in heart transplanted patients. All molecules are described, with their mode of action against HCMV, preclinical tests, clinical studies and possible resistance. All these molecules have shown anti-HCMV potential as monotherapy or in combination with others. These new approaches could be interesting to validate in clinical trials.
Collapse
Affiliation(s)
- Claire Gourin
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
| | - Sophie Alain
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
- CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
| | - Sébastien Hantz
- INSERM, CHU Limoges, University of Limoges, RESINFIT, Limoges, France
- CHU Limoges, Laboratoire de Bactériologie-Virologie-Hygiène, National Reference Center for Herpesviruses, Limoges, France
| |
Collapse
|
14
|
Bottino P, Pastrone L, Curtoni A, Bondi A, Sidoti F, Zanotto E, Cavallo R, Solidoro P, Costa C. Antiviral Approach to Cytomegalovirus Infection: An Overview of Conventional and Novel Strategies. Microorganisms 2023; 11:2372. [PMID: 37894030 PMCID: PMC10608897 DOI: 10.3390/microorganisms11102372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 10/29/2023] Open
Abstract
Human cytomegalovirus (HCMV) is a herpesvirus capable of establishing a lifelong persistence in the host through a chronic state of infection and remains an essential global concern due to its distinct life cycle, mutations, and latency. It represents a life-threatening pathogen for immunocompromised patients, such as solid organ transplanted patients, HIV-positive individuals, and hematopoietic stem cell recipients. Multiple antiviral approaches are currently available and administered in order to prevent or manage viral infections in the early stages. However, limitations due to side effects and the onset of antidrug resistance are a hurdle to their efficacy, especially for long-term therapies. Novel antiviral molecules, together with innovative approaches (e.g., genetic editing and RNA interference) are currently in study, with promising results performed in vitro and in vivo. Since HCMV is a virus able to establish latent infection, with a consequential risk of reactivation, infection management could benefit from preventive treatment for critical patients, such as immunocompromised individuals and seronegative pregnant women. This review will provide an overview of conventional antiviral clinical approaches and their mechanisms of action. Additionally, an overview of proposed and developing new molecules is provided, including nucleic-acid-based therapies and immune-mediated approaches.
Collapse
Affiliation(s)
- Paolo Bottino
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Lisa Pastrone
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Antonio Curtoni
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Alessandro Bondi
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Francesca Sidoti
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Elisa Zanotto
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Rossana Cavallo
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| | - Paolo Solidoro
- Pneumology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy;
| | - Cristina Costa
- Microbiology and Virology Unit, A.O.U. “Città della Salute e della Scienza di Torino”, 10126 Turin, Italy; (L.P.); (A.C.); (A.B.); (F.S.); (E.Z.); (R.C.)
| |
Collapse
|