Prevymis banner

PET vs Prophylaxis

Limitations of pre-emptive therapy in HSCT

Prophylaxis

It is a strategy where antiviral agents are given to a patient to prevent a primary, reactivated, or recurrent CMV infection.1

Pre-emptive therapy (PET)

It is a strategy where antiviral agents are given for an asymptomatic CMV infection detected by a specific screening assay.1

In order to prevent CMV disease, early CMV replication should be prevented. A retrospective analysis of seropositive patients monitored by qPCR has shown in a multivariate analysis that the presence of any level of CMV viremia has a substantial impact on all-cause mortality and non-relapse mortality. This effect occurs both in the early and late post-transplant period up to day +365, even despite the use of preemptive therapy.2

PET-Strategies have significantly reduced the incidence of CMV end-organ disease to 3–6% in the first three months after HCT. However, these approaches are associated with potential toxicities, the risk of viral resistance, and the continued high mortality of CMV pneumonia.2

Neutropenia and acute kidney injury (AKI) are common complications in PET. A retrospective single-center cohort study evaluated the impact of PET for CMV on toxicities in CMV-seropositive recipients of allo-HCT. The results underscore the need for safer antivirals for CMV management in HCT recipients. In multivariate models, PET increased the risk of neutropenia 1.8-fold after adjusting for transplant characteristics and duration of follow-up. In multivariate models, PET recipients had a 2.8-fold increased risk for AKI compared to no PET patients.3

References:
  1. Styczyński J, Prophylaxis vs preemptive therapy inprevention of CMV infection: new insight on prophylactic strategy after allogeneic hematopoietic cell transplantation; Acta Haematologica Polonica; 2020 Mar; 17–23
  2. Green ML et al.,Cytomegalovirus viral load and mortality after haemopoietic stem cell transplantation in the era of pre-emptive therapy: a retrospective cohort study. Lancet Haematol. 2016 Mar;3(3):e119-27.
  3. Zavras P et al., Impact of Preemptive Therapy for Cytomegalovirus on Toxicities after Allogeneic Hematopoietic Cell Transplantation in Clinical Practice: A Retrospective Single-Center Cohort Study. Biol Blood Marrow Transplant. 2020 Aug;26(8):1482-1491.