Valganciclovir is a prodrug of ganciclovir, which after oral administration quickly turns into ganciclovir, therefore all known undesirable effects associated with ganciclovir are expected for the drug
The safety profiles of valganciclovir and ganciclovir were similar for intravenous administration for 28 days. The most common adverse events were diarrhea, neutropenia and fever. Patients who received the drug Valganciclovir orally, candidiasis of the oral mucosa, headache and weakness were more frequent, and with ganciclovir intravenously - nausea and undesirable events at the injection site (phlebitis and thrombophlebitis) (see table 1).
The following table (see Table 2) presents adverse events (regardless of their severity and association with the drug) with a incidence of ≥5%, obtained in clinical studies on the use of valganciclovir in either patients with CMV retinitis, or in patients after Transplantation of solid organs. The most frequent adverse events, regardless of their severity, but according to researchers, associated with taking the drug (distant, probable or possible connection) in patients with CMV retinitis were: neutropenia, anemia, diarrhea and nausea.
Prevention of CMV infection in patients after organ transplantation
Table 2 shows the adverse events (up to 28 days after the completion of the study), regardless of their severity and the connection with taking the drug, with a incidence of ≥5%, obtained in clinical studies in patients after organ transplantation, valganciclovir or ganciclovir orally, taking medication for 10 days after transplantation and continuing to receive up to the 100th day of the post-transplant period.
The most frequent adverse reactions, regardless of severity, but according to researchers, associated with taking the drug (distant, probable or possible association) in patients after transplantation of solid organs treated prior to the 100th day of the posttransplant period: leukopenia, diarrhea, nausea, neutropenia : in patients who underwent kidney transplantation and received treatment before the 200th day of the posttransplant period: leukopenia, neutropenia, anemia and diarrhea.
Table 2. Proportion of patients with adverse events (AEs) that occurred in ≥5% of patients with CMV retinitis or after organ transplantation in clinical trials with valganciclovir organciclovir
Body systems / description | Patients with CMV retinitis | Patients after organ transplantation who received treatment on the 100th day of the post-transplant period |
Valganciclovir (n = 370) | Valganciclovir (n = 244) | Ganciclovir orally (n = 126) |
% | % | % |
From the digestive system |
Diarrhea | 38 | 30 | 29 |
Nausea | 25 | 23 | 23 |
Vomiting | 20 | 16 | 14 |
Stomach ache | 13 | 14 | 14 |
Constipation | 6 | 20 | 20 |
Pain in the upper abdomen | 6 | 9 | 6 |
Dyspepsia | 4 | 12 | 10 |
Bloating | 2 | 6 | 6 |
Ascites | - | 9 | 6 |
Impaired liver function | 3 | 9 | 1 1 |
From the body as a whole |
Fever | 26 | 13 | 14 |
Fatigability | 20 | 13 | 15 |
Swelling of the lower extremities | 5 | 21 | 16 |
Pain | 3 | 5 | 7 |
Edema | 1 | 11 | 9 |
Peripheral edema | 1 | 6 | 7 |
Weakness | 4 | 6 | 6 |
From the blood to the lymphatic system |
Neutropenia | 24 | 8 | 3 |
Anemia | 22 | 12 | 15 |
Thrombocytopenia | 5 | 5 | 5 |
Leukopenia | 4 | 14 | 7 |
Infectious complications |
Candidiasis of the oral mucosa | 20 | 3 | 3 |
From the nervous system |
Headache | 18 | 22 | 27 |
Insomnia | 14 | 20 | 16 |
Peripheral Neuropathy | 7 | 1 | 1 |
Paresthesia | 6 | 5 | 5 |
Tremor | 2 | 28 | 25 |
Dizziness (except vertigo) | 9 | 10 | 6 |
Depression | 9 | 7 | 6 |
From the skin and subcutaneous fat |
Dermatitis | 18 | 4 | 5 |
Night sweats | 7 | 3 | 4 |
Itching | 6 | 7 | 4 |
Acne | <1 | 4 | 6 |
From the respiratory system |
Cough | 16 | 6 | 8 |
Dyspnea | 9 | 11 | 10 |
Productive cough | 5 | 2 | 2 |
Discharge from the nose | 2 | 4 | 6 |
Pleural effusion | <1 | 7 | 8 |
From the sense organs |
Retinal disinsertion | 13 | - | - |
Unclear vision | 6 | 1 | 4 |
From the side of the musculoskeletal system |
Back pain | 8 | 20 | 15 |
Arthralgia | 6 | 7 | 7 |
Muscle cramps | 2 | 6 | 11 |
Pain in the extremities | 3 | 5 | 7 |
From the urinary system |
Renal insufficiency | 1 | 7 | 12 |
Dizuria | 2 | 7 | 6 |
From the immune system |
Transplant rejection reaction |
| 24 | 30 |
From the side of metabolism |
Anorexia | 5 | 3 | - |
Cachexia | 5 | - | - |
Decreased appetite | 8 | 4 | 5 |
Dehydration | 6 | 5 | 6 |
Weight loss | 9 | 3 | 3 |
From the side of the cardiovascular system |
Reduction of blood pressure | 1 | 3 | 8 |
Increased blood pressure | 3 | 18 | 15 |
Laboratory indicators |
Hyperkalemia | <1 | 14 | 14 |
Hypokalemia | 2 | 8 | 8 |
Hypomagnesemia | <1 | 8 | 8 |
Hyperglycaemia | 1 | 6 | 7 |
Hypophosphatemia | <1 | 9 | 6 |
Hypocalcemia | <1 | 4 | 6 |
Hypercreatinemia | 1 | 10 | 14 |
Postoperative complications |
Postoperative complications | 1 | 12 | 8 |
Pain in the postoperative period | 2 | 13 | 7 |
Infection of a postoperative wound | 1 | 11 | 6 |
Increasing the frequency of drainage | - | 5 | 9 |
Poor healing of the postoperative wound | <1 | 5 | 6 |
The following are listed serious adverse events, according to the company associated with taking Valganciclovir, which occurred at a frequency of less than 5% in three clinical trials and not listed above.
On the part of the blood and lymphatic system: pancytopenia, suppression of bone marrow function, aplastic anemia; febrile neutropenia; potentially life-threatening hemorrhages associated with the development of thrombocytopenia.
From the genitourinary system: decrease in the clearance of creatinine.
From the central and peripheral nervous system: convulsions, psychotic disorders, hallucinations, confusion, agitation.
On the part of the body as a whole: hypersensitivity reactions to valganciclovir. Severe neutropenia (an absolute number of neutrophils less than 500 in 1 μl) is more common in patients with CMV retinitis (16%) than in patients receiving valganciclovir (5%) or oral ganciclovir (3%) after organ transplantation before the 100th day of post-transplantation period or in patients receiving valganciclovir (10%) to the 200th day of the post-transplant period. Patients receiving both valganciclovir, and ganciclovir orally after organ transplantation to the 100th day or 200th day of the post-transplant period, compared to patients with CMV retinitis, there is a greater increase in serum creatinine concentration. Abnormal kidney function is characteristic for patients who underwent organ transplantation.
The overall safety profile of Valganciclovir does not change with an increase in the period of preventive use up to 200 days in patients after kidney transplantation from the risk group.
In patients receiving valganciclovir up to the 200th day of the post-transplant period, compared with patients receiving valganciclovir up to the 100th day of post-transplantation period, there is a slight increase in the frequency of leukopenia. The frequency of development of neutropenia, anemia and thrombocytopenia is similar in patients receiving treatment before the 100th day and 200th day of the post-transplant period.
Table 3. Changes in laboratory indicators, reported when taking Valganciclovir in adults
Changes in laboratory indicators | Patients with CMV retinitis | Patients after organ transplantation |
Valganciclovir (n = 370) | Valganciclovir (n = 244) | Ganciclovir orally (n = 126) |
% | % | % |
Neutropenia (absolute number of neutrophils / μL) |
<500 | 16 | 5 | 3 |
500 - <750 | 17 | 3 | 2 |
750 - <1000 | 17 | 5 | 2 |
Anemia (hemoglobin g / l) |
<65 | 7 | 1 | 2 |
65 - <80 | 10 | 5 | 1 |
80 - <95 | 14 | 31 | 25 |
Thrombocytopenia (platelet count / μl) |
<25000 | 3 | 0 | 2 |
25000 - <50000 | 5 | 1 | 3 |
50000 - <100000 | 21 | 18 | 21 |
Concentration of serum creatinine (mg / dL) |
>2,5 | 2 | 14 | 21 |
>1,5-2,5 | 1 1 | 45 | 47 |
Experience with ganciclovir
Because the valganciclovir is rapidly metabolized with the formation of ganciclovir, the following are undesirable phenomena noted in the treatment of ganciclovir and not mentioned above.
From the digestive system: Cholangitis, dysphagia, eructation, esophagitis, stool incontinence,flatulence, gastritis, gastrointestinal disorders, gastrointestinal bleeding, ulcerative stomatitis, pancreatitis, glossitis, hepatitis, jaundice.
On the part of the body as a whole: asthenia, bacterial, fungal and viral infections, malaise, mucositis, photosensitivity reaction, tremors, sepsis.
From the skin and subcutaneous fat: alopecia, dry skin, sweating, urticaria.
From the central and peripheral nervous system: sleep disorders, amnesia, anxiety, ataxia, coma, dry mouth, emotional disorders, hyperkinetic syndrome, hypertension, decreased libido, myoclonic twitching, nervousness, drowsiness, intellectual impairment.
From the musculoskeletal system: pain in the bones and muscles, myasthenic syndrome.
From the genitourinary system: hematuria, impotence, frequent urination.
From the endocrine system: diabetes.
From the laboratory indicators: an increase in the activity of alkaline phosphatase, creatine phosphokinase, lactate dehydrogenase in the blood, a decrease in the concentration of glucose in the blood, hypoproteinemia.
From the sense organs: amblyopia, blindness, ear pain, eye hemorrhage, eyeball pain, deafness, glaucoma, eating disorders, tinnitus, vision impairment, changes in the vitreous.
From the side of the blood and lymphatic system: eosinophilia, leukocytosis, lymphadenopathy, splenomegaly, bleeding.
From the side of the cardiovascular system: arrhythmias, including ventricular, migraine, phlebitis, tachycardia, deep vein thrombophlebitis, vasodilation.
From the respiratory system: congestion in the paranasal sinuses.
Children
Prevention of CMV infection in patients after organ transplantation
Table 4 shows the undesirable events (developed up to 28 days after the completion of the study), regardless of their severity and the connection with the drug. The table includes undesirable events with a incidence of ≥10% reported in clinical studies in children aged 3 weeks to 16 years after transplantation of solid organs who started valganciclovir for 10 days after transplantation and continued treatment until the 100th day of the post-transplant period ,as well as in children after kidney transplantation who started taking valganciclovir within 10 days after transplantation and continued treatment until the 200th day of the post-transplant period.
The overall safety profile of Valganciclovir in children does not differ from the safety profile of the drug in adults. Some adverse events have been observed in children with a greater frequency than in adults, for example, upper respiratory tract infections, fever, abdominal pain and dysuria, which may reflect the characteristics of the infant population. In the children's population there was a slight increase in the frequency of neutropenia, but this does not lead to an increase in the incidence of infections.
In children who have undergone kidney transplantation, an increase in the period of preventive use up to 200 days does not lead to an increase in the incidence of adverse events.
Table 4. Adverse events that occurred with a frequency of ≥10% in children after organ transplantation
Body systems / description | Patients of childhood after transplantation of solid organs |
Treatment with valganciclovir before the 100th day of the post-transplant period (n = 63) | Treatment with valganciclovir before the 200th day of the post-transplant period (n = 56) |
% | % |
infectious complications |
urinary tract infections | 6 | 34 |
urinary tract infections caused by e.coli | - | 13 |
upper respiratory tract infection | 22 | 34 |
from the digestive system |
diarrhea | 32 | 32 |
constipation | 11 | 5 |
nausea | 11 | 9 |
stomach ache | 6 | 18 |
vomiting | 21 | 13 |
on the part of the blood and lymphatic system |
leukopenia | 2 | 25 |
anemia | 14 | 16 |
neutropenia | 13 | 23 |
on the part of the body as a whole |
fever | 24 | 16 |
laboratory indicators |
hypercreatinemia | 2 | 16 |
from the urinary system |
hematuria | 6 | 11 |
dysuria | 2 | 18 |
from the nervous system |
tremor | 3 | 18 |
headache | 6 | 21 |
from the cardiovascular system |
increase of arterial | 22 | 16 |
pressures |
|
|
from the immune system |
graft rejection reaction | 10 | 5 |
Severe neutropenia was more often observed in children who underwent kidney transplantation and received valganciclovir up to the 200th day of the post-transplant period, compared with children receiving valganciclovir up to the 100th day of post-transplantation period, and also in comparison with adults who underwent kidney transplantation and received valganciclovir up to the 100th and 200th day of the post-transplant period.
congenital CMV infection
the limited data available indicate that the safety profile for valganciclovir or ganciclovir for up to 6 months for the treatment of congenital cMV infection in neonates aged 2 to 31 days does not differ from that in adults.
when ganciclovir was used, the most frequently reported grade 3 and 4 neutropenia (38%). only in one case, antiviral therapy was canceled because of the development of neutropenia. in other cases, neutropenia was amenable to correction without canceling therapy. In all newborns, there was an increase in indicators characterizing growth and development (height, body weight, average head circumference). when valganciclovir was used, the most frequent adverse events were neutropenia, anemia, impaired liver function, and diarrhea (it should be noted that these undesirable events were seen in patients who did not receive the drug, and more frequently than patients who received the drug). the only serious adverse events associated with treatment were neutropenia and anemia (also more frequently observed in patients who did not receive the drug).There were no statistically or clinically significant differences between patients who received and did not receive valganciclovir, in terms of growth and development (height, body weight, average head circumference).
Table 5. Changes in laboratory parameters when using valganciclovir in children.
changes in laboratory indicators | patients of pediatric age after transplantation of solid organs |
treatment with valganciclovir before the 100th day of the post-transplant period (n = 63) | treatment with valganciclovir before the 200th day of post-transplantation period (n = 56) |
% | % |
neutropenia (absolute number of neutrophils / μL) |
<500 | 5 | 30 |
500 - <750 | 8 | 7 |
750 - <1000 | 5 | 11 |
anemia (hemoglobin g / l) |
<65 | 0 | 0 |
65 - <80 | 14 | 5 |
80 - <95 | 38 | 29 |
thrombocytopenia (platelet count / μl) |
<25000 | 0 | 0 |
25000 - <50000 | 10 | 0 |
50000 - <100000 | 3 | 4 |
serum creatinine concentration (mg / dL) |
>2,5 | 2 | 5 |
>1,5-2,5 | 11 | 20 |
experience of postmarketing drug use
experience with ganciclovir and valganciclovir
because the valganciclovir rapidly and to a large extent is transformed into ganciclovir, undesirable phenomena observed with the use of ganciclovir, may develop in the treatment of valganciclovir.
undesirable phenomena described in spontaneous reports during post-marketing application of ganciclovir (orally or intravenously), not mentioned in any of the above sections,for which it is impossible to exclude a causal relationship with the drug: anaphylaxis, a decrease in fertility in men.
The undesirable phenomena described in the postmarketing use of the drug are similar to those observed in clinical trials of valganciclovir and ganciclovir.