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Intravenous Cidofovir for Peripheral Cytomegalovirus Retinitis in Patients with AIDS: A Randomized, Controlled Trial

Jacob P. Lalezari, MD; Robert J. Stagg, PharmD; Baruch D. Kuppermann, MD, PhD; Gary N. Holland, MD; Francoise Kramer, MD; David V. Ives, MD; Michael Youle, MB, ChB; Michael R. Robinson, MD; W. Lawrence Drew, MD, PhD; and Howard S. Jaffe, MD
[+] Article and Author Information

For author affiliations and current author addresses, see end of text. Grant Support: By Gilead Sciences, Inc. Requests for Reprints: Jacob P. Lalezari, MD, Quest Clinical Research, 2300 Sutter Street, Suite 202, San Francisco, CA 94115. Current Author Addresses: Dr. Lalezari: Quest Clinical Research, 2300 Sutter Street, Suite 202, San Francisco, CA 94115.


Copyright ©2004 by the American College of Physicians


Ann Intern Med. 1997;126(4):257-263. doi:10.7326/0003-4819-126-4-199702150-00001
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Background: Cytomegalovirus (CMV) retinitis is the most common intraocular infection in patients with the acquired immunodeficiency syndrome (AIDS). If left untreated, it may lead to progressive destruction of retinal tissue and blindness. Cidofovir is a nucleotide analogue of cytosine that has potent, prolonged in vitro and in vivo activity against herpesviruses, including many CMV isolates that are resistant to ganciclovir and foscarnet.

Objective: To determine whether intravenous cidofovir delays progression of previously untreated CMV retinitis.

Design: Randomized, controlled trial comparing immediate with deferred cidofovir treatment. Patients in the deferred treatment group were eligible to receive cidofovir after progression of CMV retinitis was documented by retinal photography.

Setting: Eight academic medical centers and an independent center that read retinal photographs.

Patients: 48 patients with AIDS and previously untreated peripheral CMV retinitis who were randomly assigned to immediate (n = 25) or deferred treatment (n = 23).

Intervention: Intravenous cidofovir, 5 mg/kg of body weight, once weekly for 2 weeks and then once every other week. To minimize nephrotoxicity, oral probenecid and intravenous hydration with normal saline were administered with each cidofovir infusion.

Measurements: Progression of CMV retinitis was assessed by bilateral, full-field retinal photographs that were read by an ophthalmologist who was masked to treatment assignment. Incidence of side effects, changes in visual acuity, effect on CMV shedding in urine and blood, and mortality were also assessed.

Results: The median time to progression of CMV retinitis was 22 days (95% CI, 10 to 27 days) in the deferred treatment group and 120 days (CI, 40 to 134 days) in the immediate treatment group (P < 0.001). Neutropenia (15%) and proteinuria (12%), both asymptomatic, were the most common serious adverse events considered to be possibly related to cidofovir. Cidofovir treatment was discontinued in 10 of 41 patients (24%) because of protocol-defined treatment-limiting nephrotoxicity. Transient reactions to probenecid, including mild to moderate constitutional symptoms or nausea, occurred in 23 of 41 patients (56%) and were dose limiting in 3 (7%).

Conclusions: Cidofovir was efficacious in delaying progression of previously untreated CMV retinitis. Treatment was associated with manageable side effects; strict adherence to monitoring of renal function before cidofovir was administered and concomitant administration of probenecid and saline hydration appeared to minimize drug-related nephrotoxicity.

Figures

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Figure 1.
Kaplan-Meier plot of time to progression of cytomegalovirus retinitis in the immediate and deferred cidofovir treatment groups.P

The estimated median time to progression of cytomegalovirus retinitis was 22 days (95% CI, 10 to 27 days) in the deferred treatment group and 120 days (CI, 40 to 134 days) in the immediate treatment group ( < 0.001; log-rank test).

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Grahic Jump Location
Figure 2.
Kaplan-Meier plot of survival for the immediate and deferred cidofovir treatment groups.P

The median duration of survival was 13.5 months in the immediate treatment group and 10.5 months in the deferred treatment group ( = 0.15; log-rank test).

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