Suspension of anticytomegalovirus maintenance therapy following immune recovery due to highly active antiretroviral therapy

Curi, André Luis Land; Muralha, Acácio; Muralha, Lília; Pavésio, Carlos

doi:10.1136/bjo.85.4.471

Cited by 20 publications

(6 citation statements)

References 12 publications

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“…Due to the low recurrence of CMV disease, we conclude, as previous literature reports suggest, that the withdrawal of CMV prophylaxis is a safe procedure in patients on HAART showing immune recovery 2,5,20,25,26,30,36,40,41,43,45 .…”

Section: Discussionmentioning

confidence: 61%

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Withdrawal of maintenance therapy for cytomegalovirus retinitis in AIDS patients exhibiting immunological response to HAART

Waib

Bonon

Salles

et al. 2007

Rev. Inst. Med. trop. S. Paulo

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SUMMARYBackground: Before the introduction of highly active antiretroviral therapy (HAART), CMV retinitis was a common complication in patients with advanced HIV disease and the therapy was well established; it consisted of an induction phase to control the infection with ganciclovir, followed by a lifelong maintenance phase to avoid or delay relapses. Methods: To determine the safety of CMV maintenance therapy withdrawal in patients with immune recovery after HAART, 35 patients with treated CMV retinitis, on maintenance therapy, with CD4+ cell count greater than 100 cells/mm 3 for at least three months, but almost all patients presented these values for more than six months and viral load < 30000 copies/mL, were prospectively evaluated for the recurrence of CMV disease. Maintenance therapy was withdrawal at inclusion, and patients were monitored for at least 48 weeks by clinical and ophthalmologic evaluations, and by determination of CMV viremia markers (antigenemia-pp65), CD4+/CD8+ counts and plasma HIV RNA levels. Lymphoproliferative assays were performed on 26/35 patients. Results: From 35 patients included, only one had confirmed reactivation of CMV retinitis, at day 120 of follow-up. No patient returned positive antigenemia tests. No correlation between lymphoproliferative assays and CD4+ counts was observed. Conclusion: CMV retinitis maintenance therapy discontinuation is safe for those patients with quantitative immune recovery after HAART.

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Section: Discussionmentioning

confidence: 61%

“…Studies addressing CMV immune recovery were first published in 1998 24,31,44 targeting both humoral 6 and cellular responses 23 . Clinical studies followed, demonstrating a low incidence of recurrence after withdrawal of secondary prophylaxis in small samples 4,5,7,19,25,30,32,36,41,45,46 .…”

Section: Introductionmentioning

confidence: 99%

Withdrawal of maintenance therapy for cytomegalovirus retinitis in AIDS patients exhibiting immunological response to HAART

Waib

Bonon

Salles

et al. 2007

Rev. Inst. Med. trop. S. Paulo

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“…The number of patients who were observed to discontinue prophylaxis for MAC or CMV was small and definitive conclusions cannot be drawn from this study alone. Several larger studies have also concluded that withdrawing prophylaxis for MAC and CMV is safe [7–15]. However, one case of CMV retinitis was diagnosed in this study, 6 months after the discontinuation of ganciclovir, despite impressive immunological and virological response.…”

Section: Discussionmentioning

confidence: 99%

“…This suggested the approach of discontinuing antibiotic prophylaxis in patients who experienced effective immune reconstitution, thereby reducing toxicity and drug interactions, lowering costs of care, and potentially improving adherence to antiretroviral regimens. A number of studies, both observational and randomized, confirmed the safety of discontinuing prophylaxis in patients whose CD4 cell count increased to levels indicative of a low risk of opportunistic infection [2–15]. Accordingly, the United States Public Health Service/Infectious Disease Society of America (USPHS/IDSA) guidelines were updated in 2002 [16], and specify the same or slightly more conservative CD4 count thresholds for discontinuing prophylaxis as those for initiating prophylaxis (Table 1).…”

Section: Introductionmentioning

confidence: 99%

“…A number of studies, both observational and randomized, confirmed the safety of discontinuing prophylaxis in patients whose CD4 cell Correspondence: Dr Phillip Hay, Department of GU Medicine, St George's Hospital, Blackshaw Road, London SW17 0QT, UK. Tel: 1 44 208 6721 255; fax: 1 44 208 6725 304; e-mail: phay@sghms.ac.uk count increased to levels indicative of a low risk of opportunistic infection [2][3][4][5][6][7][8][9][10][11][12][13][14][15]. Accordingly, the United States Public Health Service/Infectious Disease Society of America (USPHS/IDSA) guidelines were updated in 2002 [16], and specify the same or slightly more conservative CD4 count thresholds for discontinuing prophylaxis as those for initiating prophylaxis (Table 1).…”

Section: Introductionmentioning

confidence: 99%

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A prospective multicentre study of discontinuing prophylaxis for opportunistic infections after effective antiretroviral therapy

Green¹,

Hay²,

Dunn³

et al. 2004

HIV Medicine

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ObjectiveTo assess the medium-term safety of discontinuing prophylaxis (primary or secondary) for opportunistic infections following an effective response to antiretroviral therapy. MethodsParticipating clinical sites prospectively identified patients in whom the discontinuation of prophylaxis for any opportunistic infection was considered to be clinically indicated, although CD4 levels were not predefined. A follow-up report was subsequently sent every 6 months requesting information on changes in prophylaxis, antiretroviral drugs, new AIDS-defining events, and CD4 cell count results. ResultsProphylaxis for Pneumocystis carinii pneumonia (PCP) was withdrawn in 524 patients (426 primary and 98 secondary prophylaxis), prophylaxis for Mycobacterium avium complex (MAC) was withdrawn in 28 patients (13 primary and 15 secondary), and prophylaxis for cytomegalovirus (CMV) retinitis was withdrawn in 10 patients. CD4 counts were generally maintained above accepted prophylaxis threshold levels during the period of follow up (95-98% of the time). Total follow up to last report or re-continuation of prophylaxis was 680 and 144 person-years for patients discontinuing primary and secondary PCP prophylaxis, respectively. No cases of PCP were reported, giving incidence rates of 0.0 (upper 95% confidence limit 0.4) and 0.0 (2.1) per 100 person-years. No cases of MAC were reported, but one patient had a recurrence of CMV retinitis. PCP prophylaxis was restarted in 30 patients; no patients restarted MAC or CMV prophylaxis. ConclusionsPrevious studies have demonstrated a low risk of PCP in the short term following the withdrawal of prophylaxis in patients who have responded well to antiretroviral therapy. The present study suggests a continuing low level of risk with extended follow up, provided adequate CD4 count levels are maintained. The case of recurrent CMV retinitis in a patient with impressive immunological and virological response indicates the need for close monitoring of patients previously diagnosed with this condition.

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Human Immunodeficiency Virus (HIV)

Angus¹,

Peto²

2004

Evidence‐based Infectious Diseases

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Suspension of anticytomegalovirus maintenance therapy following immune recovery due to highly active antiretroviral therapy

Cited by 20 publications

References 12 publications

Withdrawal of maintenance therapy for cytomegalovirus retinitis in AIDS patients exhibiting immunological response to HAART

Withdrawal of maintenance therapy for cytomegalovirus retinitis in AIDS patients exhibiting immunological response to HAART

A prospective multicentre study of discontinuing prophylaxis for opportunistic infections after effective antiretroviral therapy

Human Immunodeficiency Virus (HIV)

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