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Valganciclovir in Adult Solid Organ Transplant Recipients

Pharmacokinetic and Pharmacodynamic Characteristics and Clinical Interpretation of Plasma Concentration Measurements

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Abstract

Valganciclovir and ganciclovir are widely used for the prevention of cytomegalovirus (CMV) infection in solid organ transplant recipients, with a major impact on patients’ morbidity and mortality. Oral valganciclovir, the ester prodrug of ganciclovir, has been developed to enhance the oral bioavailability of ganciclovir. It crosses the gastrointestinal barrier through peptide transporters and is then hydrolysed into ganciclovir. This review aims to describe the current knowledge of the pharmacokinetic and pharmacodynamic characteristics of this agent, and to address the issue of therapeutic drug monitoring.

Based on currently available literature, ganciclovir pharmacokinetics in adult solid organ transplant recipients receiving oral valganciclovir are characterized by bioavailability of 66±10% (mean ± SD), a maximum plasma concentration of 3.1 ± 0.8 mg/L after a dose of 450 mg and of 6.6 ± 1.9 mg/L after a dose of 900 mg, a time to reach the maximum plasma concentration of 3.0±1.0 hours, area under the plasma concentration-time curve values of 29.1±5.3mg · h/L and 51.9±18.3mg · h/L (after 450 mg and 900 mg, respectively), apparent clearance of 12.4 ± 3.8 L/h, an elimination half-life of 5.3 ± 1.5 hours and an apparent terminal volume of distribution of 101 ±36 L. The apparent clearance is highly correlated with renal function, hence the dosage needs to be adjusted in proportion to the glomerular filtration rate. Unexplained interpatient variability is limited (18% in apparent clearance and 28% in the apparent central volume of distribution). There is no indication of erratic or limited absorption in given subgroups of patients; however, this may be of concern in patients with severe malabsorption.

The in vitro pharmacodynamics of ganciclovir reveal a mean concentration producing 50% inhibition (IC50) among CMV clinical strains of 0.7 mg/L (range 0.2–1.9 mg/L). Systemic exposure of ganciclovir appears to be moderately correlated with clinical antiviral activity and haematotoxicity during CMV prophylaxis in high-risk transplant recipients. Low ganciclovir plasma concentrations have been associated with treatment failure and high concentrations with haematotoxicity and neurotoxicity, but no formal therapeutic or toxic ranges have been validated.

The pharmacokinetic parameters of ganciclovir after valganciclovir administration (bioavailability, apparent clearance and volume of distribution) are fairly predictable in adult transplant patients, with little interpatient variability beyond the effect of renal function and bodyweight. Thus ganciclovir exposure can probably be controlled with sufficient accuracy by thorough valganciclovir dosage adjustment according to patient characteristics. In addition, the therapeutic margin of ganciclovir is loosely defined. The usefulness of systematic therapeutic drug monitoring in adult transplant patients therefore appears questionable; however, studies are still needed to extend knowledge to particular subgroups of patients or dosage regimens.

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Acknowledgements

Support for this work was partly provided by internal funds and partly by an unrestricted research grant from Roche (Basel, Switzerland) for studies related to transplantation. The funding source had no role in the analysis and reporting of data, nor in the decision to submit the manuscript for publication. The authors have no conflicts of interest that are directly relevant to the content of this review.

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Authors and Affiliations

  1. Division of Clinical Pharmacology and Toxicology, University Hospital, Lausanne, Switzerland

    Nancy Perrottet, Laurent A. Decosterd, Jerome Biollaz &  Thierry Buclin

  2. Microbiology Institute, University Hospital, Lausanne, Switzerland

    Pascal Meylan

  3. Organ Transplantation Center, University Hospital, Lausanne, Switzerland

    Manuel Pascual

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  1. Nancy Perrottet
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  2. Laurent A. Decosterd
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  3. Pascal Meylan
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  4. Manuel Pascual
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  5. Jerome Biollaz
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  6. Thierry Buclin
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Correspondence to Thierry Buclin.

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Perrottet, N., Decosterd, L.A., Meylan, P. et al. Valganciclovir in Adult Solid Organ Transplant Recipients. Clin Pharmacokinet 48, 399–418 (2009). https://doi.org/10.2165/00003088-200948060-00006

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