eMedicine Specialties > Gastroenterology > Colon
Cytomegalovirus Colitis: Treatment & Medication
Updated: Oct 10, 2006
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
- Patients with HIV infection
- Recent studies have documented the profound effect of potent antiretroviral therapy on the natural history of HIV infection. Because most patients affected by CMV colitis have HIV infection, the increasing use of these newer therapies has fortuitously helped the treatment and prevention of CMV colitis.
- Patients receiving antiretroviral therapy have shown a decrease in HIV viral load, increased CD4+ lymphocytes, decreased hospitalization, and decreased opportunistic infections (eg, CMV colitis). For these patients, aggressive treatment of HIV infection is key in treating and preventing CMV infection.
- Patients who have CMV colitis benefit from antiviral therapy.
- Long-term prophylaxis with peroral ganciclovir is considered in patients infected with HIV who have CD4+ lymphocyte counts of less than 50 cells/µL.
- Patients with other types of immunosuppressive factors (eg, transplantation, long-term steroid use, renal dialysis)
- Because these patients are immunosuppressed by other illnesses or iatrogenic causes, the only treatment is ganciclovir.
- Discontinuation of steroid or immunosuppressive agents in these patients is discouraged, unless the infection is not responding to antiviral therapy.
- Patients who are not immunosuppressed: Treat with antiviral agents.
Surgical Care
- Resection should be considered only in patients with life-threatening ischemia or uncontrolled bleeding.
- Patients presenting with signs of peritonitis should undergo immediate laparotomy. Laparotomy may reveal discoloration of the serosa and small perforations.
- Patients who undergo resection for perforation should have a diverting stoma, and the incision should be allowed to heal by secondary intention.
Consultations
Because CMV colitis is usually observed as part of a multisystemic disease, the following consultations should be obtained.
- Consult an ophthalmologist to evaluate the patient for the presence of CMV retinitis. Patients should be instructed to monitor their vision and report any change in visual acuity or the presence of floaters.
- Consult a gastroenterologist to aid in diagnosis and treatment.
- Consult a surgeon for patients who may require resection or for those who develop complications.
- Infectious disease experts should be consulted to help treat CMV infection and to help exclude underlying HIV infection.
Diet
- Unless a patient has severe diarrhea, no special diet is needed.
- Patients with severe diarrhea may require bowel rest until the diarrhea subsides. Parenteral nutritional support may be needed.
Activity
- No activity restriction is usually required.
Medication
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Antivirals
Inhibit replication of target virus.
Ganciclovir (Cytovene)
Acyclic nucleoside analogue of 2'deoxyguanasine. Phosphorylates first to monophosphate form by CMV-encoded protein kinase homologue, then to diphosphate and triphosphate forms by cellular kinases, allowing for a 100-fold greater concentration in CMV-infected cells. Thought to inhibit CMV replication by competitive inhibition of viral DNA polymerases and by incorporating itself into viral DNA, causing termination of viral DNA elongation. Like acyclovir, ganciclovir is virostatic and only exerts its effect on replicating virus.
Adult
Not well absorbed PO
Induction: 5 mg/kg IV q12h for at least 21 d
Maintenance: 6 mg/kg/d IV (5 times/wk); PO ganciclovir maintenance at doses of 1 g tid is of uncertain value
Pediatric
<3 months: Not established
>3 months: Administer as in adults
Concomitant administration with cytotoxic drugs (eg, dapsone, vinblastine, doxorubicin, pentamidine, flucytosine, vincristine, amphotericin B, trimethoprim-sulfamethoxazole combinations, other nucleoside analogs) may result in additive toxicity in bone marrow, spermatogonia, and germinal layers of skin and GI mucosa (coadminister only if potential benefits outweigh risks); coadministration with imipenem-cilastatin may cause generalized seizures (use only if potential benefits outweigh risks); serum creatinine may increase following concurrent use of ganciclovir with either cyclosporine or amphotericin B; in presence of probenecid, ganciclovir renal clearance is reduced; bioavailability may increase when didanosine is administered either 2 h prior to or simultaneously; bioavailability may decrease in presence of zidovudine, while bioavailability of zidovudine is increased
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Phlebitis or pain may occur at injection site; clinical toxicity includes granulocytopenia, anemia, and thrombocytopenia; because PO ganciclovir is associated with higher rate of CMV retinitis progression compared with IV formulation, use only when benefits outweigh risks (advanced HIV disease); half-life and plasma/serum concentrations may increase as a result of reduced renal clearance; dosages > 6 mg/kg IV may result in increased toxicity; rapid infusions may result in increased toxicity; initially, reconstituted solutions of IV ganciclovir have a high pH (11); phlebitis or pain may occur at injection site despite further dilution in IV fluids; administration should be accompanied by adequate hydration; photosensitization (photoallergy or phototoxicity) may occur; myelosuppression is main dose-limiting toxicity; must be used with caution in patients with preexisting cytopenias
Foscarnet (Foscavir)
Organic analogue of inorganic pyrophosphate that inhibits replication of herpes simplex viruses, including CMV. Selectively inhibits at pyrophosphate binding site on virus-specific DNA polymerases at concentrations that do not affect cellular polymerases. Unlike ganciclovir, does not require activation by a kinase and is active in vitro.
Adult
Induction: 90 mg/kg IV q12h for 3-6 wk
Maintenance: 90-120 mg/kg/d IV
Pediatric
<12 years: Not established
>12 years: Administer as in adults
Coadministration with potentially nephrotoxic drugs (eg, aminoglycosides, amphotericin B, IV pentamidine) may increase nephrotoxicity (do not administer unless potential benefits outweigh risks); coadministration with IV pentamidine may cause hypocalcemia
Documented hypersensitivity
Pregnancy
C - Safety for use during pregnancy has not been established.
Precautions
Has adverse nephrotoxic effects and should be used with caution in patients with renal disease or those taking nephrotoxic medications (volume or saline loading may diminish renal toxicity); renal function must be monitored closely; may cause derangements in electrolytes, including calcium, phosphorous, magnesium, and potassium; seizures have been noted in some patients with electrolyte disturbances secondary to drug; anemia has been reported, and patients should be monitored closely
More on Cytomegalovirus Colitis |
| Overview: Cytomegalovirus Colitis |
| Differential Diagnoses & Workup: Cytomegalovirus Colitis |
 Treatment & Medication: Cytomegalovirus Colitis |
| Follow-up: Cytomegalovirus Colitis |
| Multimedia: Cytomegalovirus Colitis |
| References |
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References
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Further Reading
Keywords
CMV, CMV infection, Herpesviridae, herpesvirus, herpes simplex virus, HSV, Epstein-Barr virus, varicella-zoster virus, HIV, AIDS, CMV colitis, CMV gastrointestinal disease, CMV GI disease, HIV disease complications, bloody diarrhea, watery diarrhea, AIDS complications, CMV ulcerative colitis, cytomegalovirus ulcerative colitis, cytomegalovirus UC, steroid-dependent ulcerative colitis, cytomegalovirus infection, cytomegalovirus
