200.3 🩺 內科專科考前版

200.3.0.1 1️⃣ Letermovir Post-HSCT

• 480 mg PO qd × day 0-100 post-transplant
• 60% reduction in clinically significant CMV
• No myelosuppression (vs ganciclovir)
• Drug interaction: CYP3A4 substrate
• Insurance/cost considerations
• Standard of care most US HSCT centers since 2017

200.3.0.2 2️⃣ SOT Pre-emptive vs Prophylaxis

• Prophylaxis: universal antiviral × fixed duration
• Pre-emptive: monitoring PCR, treat if rising
• Choice depends on:
  • D/R status
  • Risk stratification
  • Cost
  • Center preference
• Both effective; trial data slightly favor prophylaxis for high-risk

200.3.0.3 3️⃣ CMV Retinitis Treatment Algorithm

• Induction: valganciclovir 900 mg PO bid × 14-21 days
• Maintenance: valganciclovir 900 mg PO qd until ART CD4 > 100 × 6 mo
• ART continues to immune reconstitution
• Intravitreal ganciclovir for sight-threatening
• Repeat ophthalmology q3 mo monitoring

200.3.0.4 4️⃣ Congenital CMV Workup

• Symptomatic newborn:
  • Newborn urine + saliva CMV PCR
  • Audiology baseline + serial
  • Ophthalmology
  • Brain imaging (cranial US, MRI)
  • LFT, CBC, electrolytes
  • Long follow-up for hearing + developmental
• Asymptomatic + screened +: enroll in research / surveillance

200.3.0.5 5️⃣ Maribavir Indications

• Refractory CMV (no response to ganciclovir/foscarnet)
• Resistant CMV (UL97/UL54 mutation confirmed)
• ≥ 12 yr post-transplant
• 8-week course
• Side effects: dysgeusia 50%, nausea, fatigue
• Drug interactions: CYP3A4

200.3.0.6 6️⃣ Resistance Patterns

• Ganciclovir R: UL97 mutations (M460I, A594V, L595S, C603W — most common)
• Cidofovir + Foscarnet R: UL54 polymerase mutations
• Cross-resistance: ganciclovir-R may retain susceptibility to cidofovir; UL54 mutants R to all polymerase inhibitors
• Maribavir works against ganciclovir-R (different mech)
• Test in refractory cases

200.3.0.7 7️⃣ CMV Hyperimmune Globulin (CytoGam)

• For CMV pneumonia (especially HSCT + lung transplant)
• Combine with ganciclovir
• Cost + supply issues
• Pregnancy: limited data, mixed trial results for congenital CMV prevention

200.3.0.8 8️⃣ Lung Transplant + CMV

• High-risk for CMV pneumonia + bronchiolitis obliterans
• Prolonged prophylaxis 6-12+ mo
• Universal CMV-D-/R-: maintain on prophylaxis lifelong (some centers)
• Surveillance PCR + bronchoscopy

200.3.0.9 9️⃣ 健保 / Taiwan

• 健保 valganciclovir for transplant + AIDS retinitis
• 健保 letermovir HSCT prophylaxis (recent inclusion)
• Maribavir 健保 limited (refractory/resistant indication)
• Congenital CMV screening — not universal Taiwan (some pilot programs)
• CMV antibody routine in transplant workup

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