Cross Resistance Vistide®
evaluable for progression by serial retinal photographs (43 randomized to 5 mg/kg and
Information for Patients
41 randomized to 3 mg/kg). Twenty-six and 21 patients discontinued therapy due to
Cidofovir-resistant isolates selected in vitro following exposure to increasing
The effects of age, gender, and race on cidofovir pharmacokinetics have not been
either an adverse event, intercurrent illness, excluded medication, or withdrawn consent
Patients should be advised that VISTIDE is not a cure for CMV retinitis, and that they
concentrations of cidofovir were assessed for susceptibility to ganciclovir and foscarnet4.
in the 5 mg/kg and 3 mg/kg groups, respectively. Thirty-eight of the 100 randomized
may continue to experience progression of retinitis during and following treatment.
All were cross resistant to ganciclovir, but remained susceptible to foscarnet.
INDICATION AND USAGE
patients had progressed according to masked assessment of serial retinal photographs
Patients receiving VISTIDE should be advised to have regular follow-up ophthalmologic
Ganciclovir- or ganciclovir/foscarnet-resistant isolates that are cross resistant to cidofovir
(13 randomized to 5 mg/kg and 25 randomized to 3 mg/ kg). Using retinal photographs,
examinations. Patients may also experience other manifestations of CMV disease despite
have been obtained from drug naive patients and from patients following ganciclovir
VISTIDE is indicated for the treatment of CMV retinitis in patients with acquired
FOR INTRAVENOUS INFUSION ONLY.
the median (95% CI) times to retinitis progression for the 5 mg/kg and 3 mg/kg groups
or ganciclovir/ foscarnet therapy. To date, the majority of ganciclovir-resistant isolates
immunodeficiency syndrome (AIDS). THE SAFETY AND EFFICACY OF VISTIDE HAVE
NOT FOR INTRAOCULAR INJECTION.
were 115 days (70, not reached) and 49 days (35, 52), respectively. This difference was
are UL97 gene product (phosphokinase) mutants and remain susceptible to cidofovir5.
NOT BEEN ESTABLISHED FOR TREATMENT OF OTHER CMV INFECTIONS (SUCH AS
HIV-infected patients may continue taking antiretroviral therapy, but those taking
statistically significant. Similar to Study 106, the median time to retinitis progression
Reduced susceptibility to cidofovir, however, has been reported for DNA polymerase
PNEUMONITIS OR GASTROENTERITIS), CONGENITAL OR NEONATAL CMV DISEASE, OR
zidovudine should be advised to temporarily discontinue zidovudine administration or
for the 5 mg/kg group was difficult to precisely estimate due to the limited number of
mutants of CMV which are resistant to ganciclovir6–9. To date, all clinical isolates which
CMV DISEASE IN NON-HIV-INFECTED INDIVIDUALS.
decrease their zidovudine dose by 50%, on days of VISTIDE administration only, because
patients remaining on treatment over time (4 of the 49 patients in the 5 mg/kg group
exhibit high level resistance to ganciclovir, due to mutations in both the DNA polymerase
probenecid reduces metabolic clearance of zidovudine. RENAL IMPAIRMENT IS THE MAJOR TOXICITY OF VISTIDE. CASES OF ACUTE DESCRIPTION OF CLINICAL TRIALS
were treated for 115 days or longer). Median (95% CI) times to the alternative endpoint
and UL97 genes, have been shown to be cross resistant to cidofovir. Cidofovir is active
RENAL FAILURE RESULTING IN DIALYSIS AND/OR CONTRIBUTING TO DEATH
of retinitis progression or study drug discontinuation were 49 days (38, 63) and 35
Patients should be informed of the major toxicity of VISTIDE, namely renal impairment,
against some, but not all, CMV isolates which are resistant to foscarnet10–12. The
Three phase II/III controlled trials of VISTIDE have been conducted in HIV-infected patients
HAVE OCCURRED WITH AS FEW AS ONE OR TWO DOSES OF VISTIDE. TO
days (27, 39) for the 5 mg/kg and 3 mg/kg groups, respectively. This difference was
and that dose modification, including reduction, interruption, and possibly discontinuation,
incidence of foscarnet-resistant isolates that are resistant to cidofovir is not known. REDUCE POSSIBLE NEPHROTOXICITY, INTRAVENOUS PREHYDRATION WITH
may be required. Close monitoring of renal function (routine urinalysis and serum
NORMAL SALINE AND ADMINISTRATION OF PROBENECID MUST BE USED WITH
A few triple-drug resistant isolates have been described. Genotypic analysis of two
creatinine) while on therapy should be emphasized. Delayed Versus Immediate Therapy (Study 105) EACH VISTIDE INFUSION. RENAL FUNCTION (SERUM CREATININE AND URINE CONTRAINDICATIONS
of these triple-resistant isolates revealed several point mutations in the CMV DNA
The importance of completing a full course of probenecid with each VISTIDE dose
In stage 1 of this open-label trial, conducted by the Studies of the Ocular Complications
PROTEIN) MUST BE MONITORED WITHIN 48 HOURS PRIOR TO EACH DOSE
polymerase gene. The clinical significance of the development of these cross-resistant
Initiation of therapy with VISTIDE is contraindicated in patients with a serum creatinine
should be emphasized. Patients should be warned of potential adverse events caused
of AIDS (SOCA) Clinical Research Group, 29 previously untreated patients with peripheral
OF VISTIDE AND THE DOSE OF VISTIDE MODIFIED FOR CHANGES IN RENAL
>1.5 mg/dL, a calculated creatinine clearance ≤55 mL/min, or a urine protein by probenecid (e.g., headache, nausea, vomiting, and hypersensitivity reactions).
CMV retinitis were randomized to either immediate treatment with VISTIDE (5 mg/kg
FUNCTION AS APPROPRIATE (SEE DOSAGE AND ADMINISTRATION). VISTIDE IS
≥100 mg/ dL (equivalent to ≥2+ proteinuria). CLINICAL PHARMACOLOGY
Hypersensitivity/allergic reactions may include rash, fever, chills and anaphylaxis.
once a week for 2 weeks, then 3 mg/kg every other week) or to have VISTIDE delayed
CONTRAINDICATED IN PATIENTS WHO ARE RECEIVING OTHER NEPHROTOXIC
Administration of probenecid after a meal or use of antiemetics may decrease the
until progression of CMV retinitis13. In stage 2 of this trial, an additional 35 previously
VISTIDE is contraindicated in patients receiving agents with nephrotoxic potential. Such
nausea. Prophylactic or therapeutic antihistamines and/or acetaminophen can be used
untreated patients with peripheral CMV retinitis were randomized to either immediate
agents must be discontinued at least seven days prior to starting therapy with VISTIDE. NEUTROPENIA HAS BEEN OBSERVED IN ASSOCIATION WITH VISTIDE
to ameliorate hypersensitivity reactions.
VISTIDE must be administered with probenecid. The pharmacokinetics of cidofovir,
treatment with VISTIDE (5 mg/kg once a week for 2 weeks, then 5 mg/kg every other
TREATMENT. THEREFORE, NEUTROPHIL COUNTS SHOULD BE MONITORED
VISTIDE is contraindicated in patients with hypersensitivity to cidofovir.
administered both without and with probenecid, are described below.
week), immediate treatment with VISTIDE (5 mg/kg once a week for 2 weeks, then
Patients should be advised that cidofovir causes tumors, primarily mammary
DURING VISTIDE THERAPY.
kg every other week), or to have VISTIDE delayed until progression of CMV
VISTIDE is contraindicated in patients with a history of clinically severe hypersensitivity
adenocarcinomas, in rats. VISTIDE should be considered a potential carcinogen in
The pharmacokinetics of cidofovir without probenecid were evaluated in 27
retinitis. Of the 64 patients in this study, 12 were randomized to 5 mg/kg maintenance
VISTIDE IS INDICATED ONLY FOR THE TREATMENT OF CMV RETINITIS IN
to probenecid or other sulfa-containing medications.
humans (See Carcinogenesis, Mutagenesis, & Impairment of Fertility). Women should be
HIV-infected patients with or without asymptomatic CMV infection. Dose-independent
therapy, 26 to 3 mg/kg maintenance therapy, and 26 to delayed therapy. Of the 12
PATIENTS WITH ACQUIRED IMMUNODEFICIENCY SYNDROME.
advised of the limited enrollment of women in clinical trials of VISTIDE.
pharmacokinetics were demonstrated after one hr infusions of 1.0 (n = 5), 3.0 (n = 10),
Direct intraocular injection of VISTIDE is contraindicated; direct injection of cidofovir has
patients enrolled in the 5 mg/kg maintenance group, 5 patients progressed, 5 patients
5.0 (n = 2) and 10.0 (n = 8) mg/kg (See Table 2 for pharmacokinetic parameters). There
IN ANIMAL STUDIES CIDOFOVIR WAS CARCINOGENIC, TERATOGENIC
been associated with iritis, ocular hypotony, and permanent impairment of vision.
Patients should be advised that VISTIDE caused reduced testes weight and hypospermia
discontinued therapy and 2 patients had no progression at study completion. Based on
was no evidence of cidofovir accumulation after 4 weeks of repeated administration
AND CAUSED HYPOSPERMIA (SEE CARCINOGENESIS, MUTAGENESIS, &
in animals. Such changes may occur in humans and cause infertility. Women of
masked readings of retinal photographs, the median [95% confidence interval (CI)] time
of 3 mg/kg/ week (n = 5) without probenecid. In patients with normal renal function,
IMPAIRMENT OF FERTILITY).
childbearing potential should be advised that cidofovir is embryotoxic in animals and
to retinitis progression was not reached (25, not reached) for the 5 mg/kg maintenance
approximately 80 to 100% of the VISTIDE dose was recovered unchanged in urine within
should not be used during pregnancy. Women of childbearing potential should be advised
group. Median (95% CI) time to the alternative endpoint of retinitis progression or study
24 hr (n = 27). The renal clearance of cidofovir was greater than creatinine clearance,
to use effective contraception during and for 1 month following treatment with VISTIDE.
drug discontinuation was 44 days (24, 207) for the 5 mg/kg maintenance group. Patients
Dose-dependent nephrotoxicity is the major dose-limiting toxicity related to VISTIDE
indicating renal tubular secretion contributes to the elimination of cidofovir.
Men should be advised to practice barrier contraceptive methods during and for 3 months
receiving 5 mg/kg maintenance had delayed time to retinitis progression compared to
administration. Cases of acute renal failure resulting in dialysis and/or contributing to
VISTIDE® is the brand name for cidofovir injection. The chemical name of cidofovir is
The pharmacokinetics of cidofovir administered with probenecid were evaluated in 12
patients receiving 3 mg/kg maintenance or deferred therapy.
death have occurred with as few as one or two doses of VISTIDE. Renal function (serum
1-[(S)-3-hydroxy-2-(phosphonomethoxy)propyl]cytosine dihydrate (HPMPC), with the
HIV-infected patients with or without asymptomatic CMV infection and 10 patients with
creatinine and urine protein) must be monitored within 48 hours prior to each dose of
Delayed Versus Immediate Therapy (Study 106) Drug Interactions
O and a molecular weight of 315.22 (279.19 for
relapsing CMV retinitis. Dose-independent pharmacokinetics were observed for cidofovir,
VISTIDE. Dose adjustment or discontinuation is required for changes in renal function
administered with probenecid, after one hr infusions of 3.0 (n = 12), 5.0 (n = 6),
In an open-label trial, 48 previously untreated patients with peripheral CMV retinitis
(serum creatinine and/or urine protein) while on therapy. Proteinuria, as measured
and 7.5 (n = 4) mg/kg (See Table 2). Approximately 70 to 85% of the VISTIDE dose
were randomized to either immediate treatment with VISTIDE (5 mg/kg once a week for
by urinalysis in a clinical laboratory, may be an early indicator of VISTIDE-related
Probenecid is known to interact with the metabolism or renal tubular excretion of
administered with concomitant probenecid was excreted as unchanged drug within
2 weeks, then 5 mg/kg every other week), or to have VISTIDE delayed until progression
nephrotoxicity. Continued administration of VISTIDE may lead to additional proximal
many drugs (e.g., acetaminophen, acyclovir, angiotensin-converting enzyme inhibitors,
24 hr. When VISTIDE was administered with probenecid, the renal clearance of cidofovir
of CMV retinitis14. Patient baseline characteristics and disposition are shown in Table
tubular cell injury, which may result in glycosuria, decreases in serum phosphate, uric
aminosalicylic acid, barbiturates, benzodiazepines, bumetanide, clofibrate, methotrexate,
was reduced to a level consistent with creatinine clearance, suggesting that probenecid
3. Of 25 and 23 patients in the immediate and delayed groups respectively, 23 and 21
acid, and bicarbonate, elevations in serum creatinine, and/or acute renal failure, in some
famotidine, furosemide, nonsteroidal anti-inflammatory agents, theophylline, and
blocks active renal tubular secretion of cidofovir.
were evaluable for retinitis progression as determined by retinal photography. Based on
cases, resulting in the need for dialysis. Patients with these adverse events occurring
zidovudine). Concomitant medications should be carefully assessed. Zidovudine should
masked readings of retinal photographs, the median [95% confidence interval (CI)] times
concurrently and meeting a criteria of Fanconi’s syndrome have been reported. Renal
either be temporarily discontinued or decreased by 50% when coadministered with
function that did not return to baseline after drug discontinuation has been observed in
Cidofovir Pharmacokinetic Parameters Following 3.0 and 5.0 mg/kg
to retinitis progression were 120 days (40, 134) and 22 days (10, 27) for the immediate
probenecid on the day of VISTIDE infusion. Infusions, Without and With Probenecid*
and delayed therapy groups, respectively. This difference was statistically significant.
However, because of the limited number of patients remaining on treatment over time
Intravenous normal saline hydration and oral probenecid must accompany each
PARAMETERS VISTIDE ADMINISTERED VISTIDE ADMINISTERED
(3 of 25 patients received VISTIDE for 120 days or longer), the median time to progression
VISTIDE infusion. Probenecid is known to interact with the metabolism or renal tubular
Concomitant administration of VISTIDE and agents with nephrotoxic potential
WITHOUT PROBENECID WITH PROBENECID
for the immediate therapy group was difficult to precisely estimate. Median (95% CI)
excretion of many drugs (see PRECAUTIONS). The safety of VISTIDE has not been
[e.g., intravenous aminoglycosides (e.g., tobramycin, gentamicin, and amikacin),
times to the alternative endpoint of retinitis progression or study drug discontinuation
Cidofovir is a white crystalline powder with an aqueous solubility of ≥170 mg/mL at
evaluated in patients receiving other known potentially nephrotoxic agents, such as
amphotericin B, foscarnet, intravenous pentamidine, vancomycin, and nonsteroidal
(including adverse events, withdrawn consent, and systemic CMV disease) were
pH 6–8 and a log P (octanol/aqueous buffer, pH 7.1) value of -3.3.
intravenous aminoglycosides (e.g., tobramycin, gentamicin, and amikacin), amphotericin
anti-inflammatory agents] is contraindicated. Such agents must be discontinued at least
52 days (37, 85) and 22 days (13, 27) for the immediate and delayed therapy groups,
B, foscarnet, intravenous pentamidine, vancomycin, and non-steroidal anti-inflammatory
seven days prior to starting therapy with VISTIDE.
VISTIDE is a sterile, hypertonic aqueous solution for intravenous infusion only. The
respectively. This difference was statistically significant. Time to progression estimates
solution is clear and colorless. It is supplied in clear glass vials, each containing 375 mg
from this study may not be directly comparable to estimates reported for other therapies. Carcinogenesis, Mutagenesis, & Impairment of Fertility
of anhydrous cidofovir in 5 mL aqueous solution at a concentration of 75 mg/mL. The
Preexisting Renal Impairment
formulation is pH-adjusted to 7.4 with sodium hydroxide and/or hydrochloric acid and
Patient Characteristics and Disposition (Study 106)
Chronic, two-year carcinogenicity studies in rats and mice have not been carried out to
Initiation of therapy with VISTIDE is contraindicated in patients with a baseline
contains no preservatives. The appropriate volume of VISTIDE must be removed from the
evaluate the carcinogenic potential of cidofovir. However, a 26-week toxicology study
serum creatinine >1.5 mg/dL, a creatinine clearance ≤55 mL/min, or a urine protein
single-use vial and diluted prior to administration (see DOSAGE AND ADMINISTRATION). Immediate Therapy Delayed Therapy
evaluating once weekly subscapular subcutaneous injections of cidofovir in rats was
≥100 mg/ dL (equivalent to ≥2+ proteinuria).
terminated at 19 weeks because of the induction, in females, of palpable masses, the
first of which was detected after six doses. The masses were diagnosed as mammary
Hematological Toxicity Mechanism of Action
adenocarcinomas which developed at doses as low as 0.6 mg/kg/week, equivalent to
Neutropenia may occur during VISTIDE therapy. Neutrophil count should be monitored
0.04 times the human systemic exposure at the recommended intravenous VISTIDE dose
Cidofovir suppresses cytomegalovirus (CMV) replication by selective inhibition of viral
DNA synthesis. Biochemical data support selective inhibition of CMV DNA polymerase
* See DOSAGE AND ADMINISTRATION Decreased Intraocular Pressure/Ocular Hypotony
by cidofovir diphosphate, the active intracellular metabolite of cidofovir. Cidofovir
In a 26-week intravenous toxicology study in which rats received 0.6, 3, or 15 mg/kg
diphosphate inhibits herpesvirus polymerases at concentrations that are 8- to 600-fold
cidofovir once weekly, a significant increase in mammary adenocarcinomas in female
Decreased intraocular pressure may occur during VISTIDE therapy, and in some instances
In vitro, cidofovir was less than 6% bound to plasma or serum proteins over the cidofovir
lower than those needed to inhibit human cellular DNA polymerases alpha, beta, and
rats as well as a significant incidence of Zymbal’s gland carcinomas in male and female
has been associated with decreased visual acuity. Intraocular pressure should be
concentration range 0.25 to 25 µg/mL. CSF concentrations of cidofovir following
gamma1, 2, 3. Incorporation of cidofovir into the growing viral DNA chain results in
rats were seen at the high dose but not at the lower two doses. The high dose was
intravenous infusion of VISTIDE 5 mg/kg with concomitant probenecid and intravenous
reductions in the rate of viral DNA synthesis.
equivalent to 1.1 times the human systemic exposure at the recommended dose of
hydration were undetectable (<0.1 µg/mL, assay detection threshold) at 15 minutes
VISTIDE, based on comparisons of AUC measurements. In light of the results of these
In Vitro Susceptibility
after the end of a 1 hr infusion in one patient whose corresponding serum concentration
studies, cidofovir should be considered to be a carcinogen in rats as well as a potential
Decreased serum bicarbonate associated with proximal tubule injury and renal wasting
Cidofovir is active in vitro against a variety of laboratory and clinical isolates of CMV and
syndrome (including Fanconi’s syndrome) have been reported in patients receiving
other herpesviruses (Table 1). Controlled clinical studies of efficacy have been limited to
VISTIDE (see ADVERSE REACTIONS). Cases of metabolic acidosis in association with liver
Cynomolgus monkeys received intravenous cidofovir, alone and in conjunction with
patients with AIDS and CMV retinitis.
dysfunction and pancreatitis resulting in death have been reported in patients receiving
concomitant oral probenecid, intravenously once weekly for 52 weeks at doses
resulting in exposures of approximately 0.7 times the human systemic exposure at the
Cidofovir Inhibition of Virus Multiplication in Cell Culture
The pharmacokinetics of zidovudine were evaluated in 10 patients receiving zidovudine
recommended dose of VISTIDE. No tumors were detected. However, the study was not
alone or with intravenous cidofovir (without probenecid). There was no evidence of an
designed as a carcinogenicity study due to the small number of animals at each dose
Virus IC (µM)
effect of cidofovir on the pharmacokinetics of zidovudine.
and the short duration of treatment.
Due to the potential for increased nephrotoxicity, doses greater than the recommended
No mutagenic response was observed in microbial mutagenicity assays involving
a One patient died 2 weeks after withdrawing consent.
dose must not be administered and the frequency or rate of administration must not be
Salmonella typhimurium (Ames) and Escherichia coli in the presence and absence of
b Two patients on immediate therapy were diagnosed with CMV disease and discontinued from study.
exceeded (see DOSAGE AND ADMINISTRATION).
metabolic activation. An increase in micronucleated polychromatic erythrocytes in vivo
One patient on delayed therapy was diagnosed with CMV gastrointestinal disease. Resistance
was seen in mice receiving ≥2000 mg/kg, a dosage approximately 65-fold higher than
Pharmacokinetic data collected from subjects with creatinine clearance values as low
VISTIDE is formulated for intravenous infusion only and must not be administered by
CMV retinitis progression not confirmed by retinal photography.
the maximum recommended clinical intravenous VISTIDE dose based on body surface
CMV isolates with reduced susceptibility to cidofovir have been selected in vitro in the
as 11 mL/min indicate that cidofovir clearance decreases proportionally with creatinine
intraocular injection. Administration of VISTIDE by infusion must be accompanied by oral
area estimations. Cidofovir induced chromosomal aberrations in human peripheral blood
presence of high concentrations of cidofovir4. IC values for selected resistant isolates
probenecid and intravenous saline prehydration (see DOSAGE AND ADMINISTRATION).
Dose-response study of VISTIDE (Study 107)
lymphocytes in vitro without metabolic activation. At the 4 cidofovir levels tested, the
High-flux hemodialysis has been shown to reduce the serum levels of cidofovir by
percentage of damaged metaphases and number of aberrations per cell increased in a
There are insufficient data at this time to assess the frequency or the clinical significance
In an open-label trial, 100 patients with relapsing CMV retinitis were randomized to
receive 5 mg/kg once a week for 2 weeks and then either 5 mg/kg (n = 49) or 3 mg/ kg
Uveitis or iritis was reported in clinical trials and during postmarketing in patients
of the development of resistant isolates following VISTIDE administration to patients.
Initiation of therapy with VISTIDE is contraindicated in patients with serum creatinine
(n = 51) every other week. Enrolled patients had been diagnosed with CMV retinitis
receiving VISTIDE therapy. Treatment with topical corticosteroids with or without topical
Studies showed that cidofovir caused inhibition of spermatogenesis in rats and monkeys.
The possibility of viral resistance should be considered for patients who show a poor
>1.5 mg/dL, a calculated creatinine clearance ≤55 mL/min, or a urine protein
an average of 390 days prior to randomization and had received a median of 3.8 prior
cycloplegic agents should be considered. Patients should be monitored for signs and
However, no adverse effects on fertility or reproduction were seen following once weekly
clinical response or experience recurrent retinitis progression during therapy.
≥100 mg/ dL (equivalent to ≥2+ proteinuria) (See CONTRAINDICATIONS).
courses of systemic CMV therapy. Eighty-four of the 100 patients were considered
symptoms of uveitis/iritis during VISTIDE therapy.
intravenous injections of cidofovir in male rats for 13 consecutive weeks at doses up
to 15 mg/kg/week (equivalent to 1.1 times the recommended human dose based on
Serious Clinical Adverse Events or Laboratory Abnormalities All Clinical Adverse Events, Laboratory Abnormalities or Intercurrent
Cherrington JM, Mulato AS, Fuller MD, Chen MS. In Vitro Selection of a
AUC comparisons). Female rats dosed intravenously once weekly at 1.2 mg/kg/week
Occurring in >5% of Patients Illnesses Regardless of Severity Occurring in >15% of Patients
Human Cytomegalovirus (HCMV) that is Resistant to Cidofovir. 35th International
VISTIDE is contraindicated in patients with a serum creatinine concentration
(equivalent to 0.09 times the recommended human dose based on AUC) or higher, for
Conference on Antimicrobial Agents and Chemotherapy (ICAAC), San Francisco,
dL, a calculated creatinine clearance ≤55 mL/min, or a urine protein
up to 6 weeks prior to mating and for 2 weeks post mating had decreased litter sizes
# patients (%)
≥100 mg/dL (equivalent to ≥2+ proteinuria). # patients (%)
and live births per litter and increased early resorptions per litter. Peri- and post-natal development studies in which female rats received subcutaneous injections of cidofovir
Stanat SC, Reardon JE, Erice A, Jordan MC, Drew WL, and Biron KK. Ganciclovir-
once daily at doses up to 1.0 mg/kg/day from day 7 of gestation through day 21
Probenecid must be administered orally with each VISTIDE dose. Two grams must be
Resistant Cytomegalovirus Clinical Isolates: Mode of Resistance to Ganciclovir.
postpartum (approximately 5 weeks) resulted in no adverse effects on viability, growth,
administered 3 hr prior to the VISTIDE dose and one gram administered at 2 and again at
Antimicrob Agents Chemother35:2191–2197, 1991.
behavior, sexual maturation or reproductive capacity in the offspring.
8 hr after completion of the 1 hr VISTIDE infusion (for a total of 4 grams).
Sullivan V, Biron KK, Talarico C, Stanat SC, Davis M, Pozzi M, and Coen DM. A
Decreased Serum Bicarbonate (≤16 mEq/L)
Ingestion of food prior to each dose of probenecid may reduce drug-related nausea and
Point Mutation in the Human Cytomegalovirus DNA Polymerase Gene Confers
vomiting. Administration of an antiemetic may reduce the potential for nausea associated
Resistance to Ganciclovir and phosphonylmethoxyalkyl Derivatives. Antimicrob
with probenecid ingestion. In patients who develop allergic or hypersensitivity symptoms
Agents Chemother37:19–25, 1993.
Cidofovir was embryotoxic (reduced fetal body weights) in rats at 1.5 mg/kg/day and
to probenecid, the use of an appropriate prophylactic or therapeutic antihistamine and/or
in rabbits at 1.0 mg/kg/day, doses which were also maternally toxic, following daily
acetaminophen should be considered (see CONTRAINDICATIONS).
Tatarowicz WA, Lurain NS, and Thompson KD. A Ganciclovir-Resistant Clinical
intravenous dosing during the period of organogenesis. The no-observable-effect
Isolate of Human Cytomegalovirus Exhibiting Cross-Resistance to other DNA
levels for embryotoxicity in rats (0.5 mg/kg/day) and in rabbits (0.25 mg/kg/day) were
Polymerase Inhibitors. J Infect Dis166:904–907, 1992.
approximately 0.04 and 0.05 times the clinical dose (5 mg/kg every other week) based
Patients must receive at least one liter of 0.9% (normal) saline solution intravenously
on AUC, respectively. An increased incidence of fetal external, soft tissue and skeletal
with each infusion of VISTIDE. The saline solution should be infused over a 1–2 hr
Lurain NS, Thompson KD, Holmes EW, and Read GS. Point Mutations in the DNA
period immediately before the VISTIDE infusion. Patients who can tolerate the
anomalies (meningocele, short snout, and short maxillary bones) occurred in rabbits at
Polymerase Gene of Human Cytomegalovirus that Result in Resistance to Antiviral
additional fluid load should receive a second liter. If administered, the second liter
the high dose (1.0 mg/kg/day) which was also maternally toxic. There are no adequate
Agents. J Virol66:7146–7152, 1992.
a Patients receiving 5 mg/kg maintenance regimen in Studies 105, 106 and 107.
of saline should be initiated either at the start of the VISTIDE infusion or immediately
and well-controlled studies in pregnant women. VISTIDE should be used during
b Defined as decreased intraocular pressure (IOP) to ≤50% that at baseline. Based on 70 patients
afterwards, and infused over a 1 to 3 hr period.
pregnancy only if the potential benefit justifies the potential risk to the fetus.
Smith IL, Cherrington JM, Jiles RE, Fuller MD, Freeman WR, Spector SA. High-level
receiving 5 mg/kg maintenance dosing (Studies 105, 106 and 107), for whom baseline and
Method of Preparation and Administration
Resistance of Cytomegalovirus to Ganciclovir is Associated with Alterations in both
follow-up IOP determinations were recorded.
the UL97 and DNA Polymerase Genes. J Infect Dis176:69–77, 1997.
Inspect vials visually for particulate matter and discoloration prior to administration.
It is not known whether cidofovir is excreted in human milk. Since many drugs are
The most frequently reported adverse events regardless of relationship to study drugs
If particulate matter or discoloration is observed, the vial should not be used. With a
excreted in human milk and because of the potential for adverse reactions as well as
(cidofovir or probenecid) or severity are shown in Table 5.
Sullivan V and Coen DM. Isolation of Foscarnet-Resistant Human Cytomegalovirus
syringe, extract the appropriate volume of VISTIDE from the vial and transfer the dose
the potential for tumorigenicity shown for cidofovir in animal studies, VISTIDE should not
to an infusion bag containing 100 mL 0.9% (normal) saline solution. Infuse the entire
Patterns of Resistance and Sensitivity to Other Antiviral Drugs. J Infect Dis
The following additional list of adverse events/intercurrent illnesses have been observed
be administered to nursing mothers. The U.S. Public Health Service Centers for Disease
volume intravenously into the patient at a constant rate over a 1 hr period. Use of a
in clinical studies of VISTIDE and are listed below regardless of causal relationship to
Control and Prevention advises HIV-infected women not to breast-feed to avoid postnatal
standard infusion pump for administration is recommended.
VISTIDE. Evaluation of these reports was difficult because of the diverse manifestations
transmission of HIV to a child who may not yet be infected.
11. Snoeck R, Andrei G, and De Clercq E. Patterns of Resistance and Sensitivity
of the underlying disease and because most patients received numerous concomitant
It is recommended that VISTIDE infusion admixtures be administered within 24 hr of
to Antiviral Compounds of Drug-Resistant Strains of Human Cytomegalovirus
preparation and that refrigerator or freezer storage not be used to extend this 24 hr limit.
Selected in Vitro. Eur J Clin Microbiol Infect Dis15:574–579, 1996.
Safety and effectiveness in children have not been studied. The use of VISTIDE in children
Body as a Whole: abdominal pain, accidental injury, AIDS, allergic reaction, back pain,
If admixtures are not intended for immediate use, they may be stored under refrigeration
a Patients receiving 5 mg/kg maintenance regimen in Studies 106 and 107.
with AIDS warrants extreme caution due to the risk of long-term carcinogenicity and
catheter blocked, cellulitis, chest pain, chills and fever, cryptococcosis, cyst, death,
(2–8 °C) for no more than 24 hr. Refrigerated admixtures should be allowed to equilibrate
Baldanti F, Underwood MR, Stanat SC, Biron KK, Chou S, Sarasini A, Silini E, and
reproductive toxicity. Administration of VISTIDE to children should be undertaken only
face edema, flu-like syndrome, hypothermia, injection site reaction, malaise, mucous
Reporting of Adverse Reactions
Gerna G. Single Amino Acid Changes in the DNA Polymerase Confer Foscarnet
after careful evaluation and only if the potential benefits of treatment outweigh the risks.
membrane disorder, neck pain, overdose, photosensitivity reaction, sarcoma, sepsis
Resistance and Slow-Growth Phenotype, While Mutations in the UL97-Encoded
Malignancies or serious adverse reactions that occur in patients who have received
The chemical stability of VISTIDE admixtures was demonstrated in polyvinyl chloride
Phosphotransferase Confer Ganciclovir Resistance in Three Double-Resistant
VISTIDE should be reported to Gilead in writing to the Director of Clinical Research, Gilead
composition and ethylene/propylene copolymer composition commercial infusion
Cardiovascular System: cardiomyopathy, cardiovascular disorder, congestive heart
Human Cytomegalovirus Strains Recovered from Patients with AIDS. J Virol
Sciences, Inc., 333 Lakeside Drive, Foster City, CA 94404 or by calling 1-800-GILEAD-5
bags, and in glass bottles. No data are available to support the addition of other 70:1390–1395, 1996.
No studies of the safety or efficacy of VISTIDE in patients over the age of 60 have been
failure, hypertension, hypotension, migraine, pallor, peripheral vascular disorder,
(445-3235), or to FDA MedWatch 1-800-FDA-1088/fax 1-800-FDA-0178. drugs or supplements to the cidofovir admixture for concurrent administration.
conducted. Since elderly individuals frequently have reduced glomerular filtration,
phlebitis, postural hypotension, shock, syncope, tachycardia, vascular disorder, edema
VISTIDE is supplied in single-use vials. Partially used vials should be discarded (see
13. The Studies of Ocular Complications of AIDS Research Group in Collaboration
particular attention should be paid to assessing renal function before and during VISTIDE
Digestive System: cholangitis, colitis, constipation, esophagitis, dyspepsia, dysphagia,
with the AIDS Clinical Trials Group. Cidofovir (HPMPC) for the Treatment
administration (see DOSAGE AND ADMINISTRATION).
Two cases of cidofovir overdose have been reported. These patients received single
fecal incontinence, flatulence, gastritis, gastrointestinal hemorrhage, gingivitis, hepatitis,
of Cytomegalovirus Retinitis in Patients with AIDS: the HPMPC Peripheral
doses of VISTIDE at 16.3 mg/kg and 17.4 mg/kg, respectively, with concomitant oral
Compatibility with Ringer’s solution, Lactated Ringer’s solution or bacteriostatic
hepatomegaly, hepatosplenomegaly, jaundice, abnormal liver function, liver damage,
Cytomegalovirus Retinitis Trial. Ann Intern Med126:264–274, 1997. ADVERSE REACTIONS
probenecid and intravenous hydration. In both cases, the patients were hospitalized
infusion fluids has not been evaluated.
liver necrosis, melena, pancreatitis, proctitis, rectal disorder, stomatitis, aphthous
and received oral probenecid (one gram three times daily) and vigorous intravenous
Nephrotoxicity: Renal toxicity, as manifested by ≥2+ proteinuria, serum stomatitis, tongue discoloration, mouth ulceration, tooth caries Handling and Disposal
14. Lalezari JP, Stagg RJ, Kupperman BD, et al. Intravenous Cidofovir for Peripheral
hydration with normal saline for 3 to 5 days. Significant changes in renal function were
creatinine elevations of ≥0.4 mg/dL, or decreased creatinine clearance
Cytomegalovirus Retinitis in Patients with AIDS. A Randomized, Controlled Trial.
Due to the mutagenic properties of cidofovir, adequate precautions including the use of
≤55 mL/ min, occurred in 79 of 135 (59%) patients receiving VISTIDE at a Endocrine System: adrenal cortex insufficiency
appropriate safety equipment are recommended for the preparation, administration, and
Ann Intern Med126:257–263, 1997. DOSAGE AND ADMINISTRATION
maintenance dose of 5 mg/kg every other week. Maintenance dose reductions
disposal of VISTIDE. The National Institutes of Health presently recommends that such
Hemic & Lymphatic System: hypochromic anemia, leukocytosis, leukopenia,
from 5 mg/kg to 3 mg/kg due to proteinuria or serum creatinine elevations were
VISTIDE MUST NOT BE ADMINISTERED BY INTRAOCULAR INJECTION.
agents be prepared in a Class II laminar flow biological safety cabinet and that personnel
lymphadenopathy, lymphoma like reaction, pancytopenia, splenic disorder, splenomegaly,
made in 12 of 41 (29%) patients who had not received prior therapy for CMV
preparing drugs of this class wear surgical gloves and a closed front surgical-type gown
thrombocytopenia, thrombocytopenic purpura
retinitis (Study 106) and in 19 of 74 (26%) patients who had received prior therapy
with knit cuffs. If VISTIDE contacts the skin, wash membranes and flush thoroughly with water. Excess VISTIDE and all other materials used in the admixture preparation
for CMV retinitis (Study 107). Prior foscarnet use has been associated with an
THE RECOMMENDED DOSAGE, FREQUENCY, OR INFUSION RATE MUST NOT BE
Metabolic & Nutritional System: cachexia, dehydration, edema, hypercalcemia,
and administration should be placed in a leak-proof, puncture-proof container. The
increased risk of nephrotoxicity; therefore, such patients must be monitored
EXCEEDED. VISTIDE MUST BE DILUTED IN 100 MILLILITERS 0.9% (NORMAL)
hyperglycemia, hyperkalemia, hyperlipemia, hypocalcemia, hypoglycemia, hypoglycemic
2010 Gilead Sciences, Inc. All rights reserved.
SALINE PRIOR TO ADMINISTRATION. TO MINIMIZE POTENTIAL NEPHROTOXICITY,
recommended method of disposal is high temperature incineration.
closely (see CONTRAINDICATIONS, WARNINGS, DOSAGE AND ADMINISTRATION).
reaction, hypokalemia, hypomagnesemia, hyponatremia, hypophosphatemia, PROBENECID AND INTRAVENOUS SALINE PREHYDRATION MUST BE ADMINISTERED
hypoproteinemia, increased alkaline phosphatase, increased BUN, increased lactic
Patient Monitoring Neutropenia: In clinical trials, at the 5 mg/kg maintenance dose, a decrease
dehydrogenase, increased SGOT, increased SGPT, peripheral edema, respiratory
Serum creatinine and urine protein must be monitored within 48 hours prior to each
in absolute neutrophil count to ≤500 cells/mm3 occurred in 24% of patients.
alkalosis, thirst, weight loss, weight gain
dose. White blood cell counts with differential should be monitored prior to each dose.
Granulocyte colony stimulating factor (GCSF) was used in 39% of patients.
The recommended induction dose of VISTIDE for patients with a serum creatinine
In patients with proteinuria, intravenous hydration should be administered and the test
Musculoskeletal System: arthralgia, arthrosis, bone necrosis, bone pain, joint disorder,
Decreased Intraocular Pressure/Ocular Hypotony: Among the subset of
of ≤1.5 mg/dL, a calculated creatinine clearance >55 mL/min, and a urine protein
repeated. Intraocular pressure, visual acuity and ocular symptoms should be monitored
leg cramps, myalgia, myasthenia, pathological fracture
<100 mg/dL (equivalent to <2+ proteinuria) is 5 mg/kg body weight (given as an
patients monitored for intraocular pressure changes, a ≥50% decrease from
intravenous infusion at a constant rate over 1 hr) administered once weekly for two
baseline intraocular pressure was reported in 17 of 70 (24%) patients at
Nervous System: abnormal dreams, abnormal gait, acute brain syndrome, agitation,
consecutive weeks. Because serum creatinine in patients with advanced AIDS and CMV
the 5 mg/kg maintenance dose. Severe hypotony (intraocular pressure of
amnesia, anxiety, ataxia, cerebrovascular disorder, confusion, convulsion, delirium,
retinitis may not provide a complete picture of the patient’s underlying renal status, it
0–1 mm Hg) has been reported in 3 patients. Risk of ocular hypotony may be
dementia, depression, dizziness, drug dependence, dry mouth, encephalopathy,
is important to utilize the Cockcroft-Gault formula to more precisely estimate creatinine
VISTIDE (cidofovir injection) 75 mg/mL for intravenous infusion, is supplied as a
increased in patients with preexisting diabetes mellitus.
facial paralysis, hallucinations, hemiplegia, hyperesthesia, hypertonia, hypotony,
clearance (CrCl). As creatinine clearance is dependent on serum creatinine and patient
non-preserved solution in single-use clear glass vials as follows:
incoordination, increased libido, insomnia, myoclonus, nervousness, neuropathy,
weight, it is necessary to calculate clearance prior to initiation of VISTIDE. CrCl (mL/min)
Anterior Uveitis/Iritis: Uveitis or iritis has been reported in clinical trials and
paresthesia, personality disorder, somnolence, speech disorder, tremor, twitching,
375 mg in a 5 mL vial in a single-unit carton
should be calculated according to the following formula:
during postmarketing in patients receiving VISTIDE therapy. Uveitis or iritis
VISTIDE should be stored at controlled room temperature 20–25 °C (68–77 °F).
was reported in 15 of 135 (11%) patients receiving 5 mg/kg maintenance
Respiratory System: asthma, bronchitis, epistaxis, hemoptysis, hiccup, hyperventilation,
VISTIDE® (cidofovir injection) is covered by U.S. Patent No. 5,142,051 and its foreign
dosing. Treatment with topical corticosteroids with or without topical
hypoxia, increased sputum, larynx edema, lung disorder, pharyngitis, pneumothorax,
counterparts. Other patents pending.
cycloplegic agents may be considered. Patients should be monitored for signs
and symptoms of uveitis/iritis during VISTIDE therapy. REFERENCES Skin & Appendages: acne, angioedema, dry skin, eczema, exfoliative dermatitis,
[140-age (years)] × [body wt (kg)] × 0.85
Metabolic Acidosis: A diagnosis of Fanconi’s syndrome, as manifested by
furunculosis, herpes simplex, nail disorder, pruritus, rash, seborrhea, skin discoloration,
multiple abnormalities of proximal renal tubular function, was reported in 1%
Ho HT, Woods KL, Bronson JJ, De Boeck H, Martin JC and Hitchcock MJM.
skin disorder, skin hypertrophy, skin ulcer, sweating, urticaria
Intracellular Metabolism of the Antiherpesvirus Agent (S)-1-[3-hydroxy-2-
of patients. Decreases in serum bicarbonate to ≤16 mEq/L occurred in 16%
(phosphonylmethoxy)propyl]cytosine. Mol Pharmacol41:197–202, 1992.
of cidofovir-treated patients. Cases of metabolic acidosis in association with
Special Senses: abnormal vision, amblyopia, blindness, cataract, conjunctivitis, corneal
The recommended maintenance dose of VISTIDE is 5 mg/kg body weight (given as an
liver dysfunction and pancreatitis resulting in death have been reported in
lesion, corneal opacity, diplopia, dry eyes, ear disorder, ear pain, eye disorder, eye
intravenous infusion at a constant rate over 1 hr), administered once every 2 weeks.
Cherrington JM, Allen SJW, McKee BH, and Chen MS. Kinetic Analysis of
pain, hyperacusis, iritis, keratitis, miosis, otitis externa, otitis media, refraction disorder, retinal detachment, retinal disorder, taste perversion, tinnitus, uveitis, visual field defect,
the Interaction Between the Diphosphate of (S)-1-(3-hydroxy-2-
In clinical trials, VISTIDE was withdrawn due to adverse events in 39% of patients
phosphonylmethoxypropyl)cytosine, zalcitabineTP, zidovudineTP, and FIAUTP with
Changes in Renal Function During VISTIDE Therapy
treated with 5 mg/kg every other week as maintenance therapy.
Human DNA Polymerases b and g. Biochem Pharmacol48:1986–1988, 1994. Urogenital System: decreased creatinine clearance, dysuria, glycosuria, hematuria,
The maintenance dose of VISTIDE must be reduced from 5 mg/kg to 3 mg/kg for an
The incidence of adverse reactions reported as serious in three controlled clinical
kidney stone, mastitis, metorrhagia, nocturia, polyuria, prostatic disorder, toxic
increase in serum creatinine of 0.3–0.4 mg/dL above baseline. VISTIDE therapy must
Xiong X, Smith JL, Kim C, Huang E, and Chen MS. Kinetic Analysis of the Interaction
studies in patients with CMV retinitis, regardless of presumed relationship to drug,
nephrophathy, urethritis, urinary casts, urinary incontinence, urinary retention, urinary
be discontinued for an increase in serum creatinine of ≥0.5 mg/dL above baseline or
of Cidofovir Diphosphate with Human Cytomegalovirus DNA Polymerase. Biochem Pharmacol51:1563–1567, 1996.
„50 Jahre VDD“ Jubiläums – Kongress 2007 Bundesverband Deutscher Ernährungsmediziner (BDEM) e. V. Verband der Oecotrophologen (VDOE) e. V. D I A B E T E S M E L L I T U S Update Diabetes mellitus – neue Medikamente Andreas Hamann, Prof. Dr. med., Diabetes-Klinik Bad Nauheim GmbH, Campus für Herz und Gefäßmedizin, Bad Nauheim und Abteilung Innere Medizin I und K