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Antiviral — CMV Treatment (IV) / Retinitis / Transplant Pregnancy: Contraindicated — teratogenic and embryotoxic in animal studies; women of childbearing age must use effective contraception during and 30 days after treatment; men 90 days after

Ganciclovir

Brand names: Cymevene

Adult dose

Dose: CMV induction: 5 mg/kg IV every 12 hours × 14–21 days; CMV maintenance: 5 mg/kg IV once daily; Prevention post-transplant: 5 mg/kg IV once daily × 7–14 days then switch to valganciclovir
Route: Intravenous infusion over 1 hour
Frequency: Every 12 hours (induction); once daily (maintenance)
Max: 10 mg/kg/day (induction)
IV ganciclovir reserved for: CMV retinitis, CMV disease in severely immunocompromised patients unable to take oral therapy, and transplant induction. Switch to oral valganciclovir once tolerating oral route — equivalent efficacy. Requires central line or large peripheral vein — highly alkaline (pH 11). MHRA: teratogenic and carcinogenic — handle with cytotoxic precautions.

Paediatric dose

Dose: 5 mg/kg mg/kg
Route: IV
Frequency: Every 12 hours (induction); once daily (maintenance)
Max: 5 mg/kg per dose
BNFc: used in congenital CMV (neonates: 6 mg/kg IV every 12 hours × 6 weeks); paediatric transplant — specialist ID/virology guidance

Dose adjustments

Renal

CrCl 50–69: 2.5 mg/kg every 12 hours; CrCl 25–49: 2.5 mg/kg every 24 hours; CrCl 10–24: 1.25 mg/kg every 24 hours; CrCl <10: 1.25 mg/kg 3x/week post-dialysis

Hepatic

No dose adjustment required

Paediatric weight-based calculator

BNFc: used in congenital CMV (neonates: 6 mg/kg IV every 12 hours × 6 weeks); paediatric transplant — specialist ID/virology guidance

Clinical pearls

  • Congenital CMV: 6 mg/kg IV every 12 hours × 6 weeks significantly reduces hearing loss and neurodevelopmental sequelae — one of few interventions that alters outcome in congenital CMV
  • Myelosuppression management: G-CSF (filgrastim) can be used to support neutrophil count during treatment — allows continuation in cases where myelosuppression would otherwise require dose reduction
  • Handle as cytotoxic: ganciclovir is classified as hazardous (carcinogenic, teratogenic, embryotoxic) — prepare in pharmacy under laminar flow; wear gloves; avoid skin contact
  • Switch to valganciclovir oral once tolerating oral — 900 mg BD achieves equivalent ganciclovir exposure to 5 mg/kg IV BD

Contraindications

  • Absolute neutrophil count <500/mm³
  • Platelet count <25,000/mm³
  • Hypersensitivity to ganciclovir or valganciclovir

Side effects

  • Myelosuppression (neutropenia, thrombocytopaenia — dose-limiting)
  • Anaemia
  • Nephrotoxicity
  • Seizures
  • Confusion
  • Fever
  • Phlebitis (IV)
  • Teratogenicity
  • Carcinogenicity (animal data)

Interactions

  • Zidovudine (AZT) — additive myelosuppression — avoid concurrent use or monitor closely
  • Imipenem-cilastatin — risk of seizures (avoid combination)
  • Mycophenolate mofetil — increased myelosuppression (both myelosuppressive; monitor FBC)
  • Probenecid — increases ganciclovir levels (tubular secretion blocked)
  • Didanosine — increased didanosine levels

Monitoring

  • FBC twice weekly during induction, weekly during maintenance (neutropenia/thrombocytopaenia)
  • Renal function (dose adjustment)
  • CMV viral load (quantitative PCR)
  • Ophthalmology review (CMV retinitis)

Reference: BNFc; BNF 90; BHIVA HIV Guidelines; NICE Transplant Immunosuppression Guidance; Kimberlin Congenital CMV Trial NEJM 2015. Verify against your local formulary and the latest BNF before prescribing.

Related

Curated clinical cross-links plus same-class fallbacks.

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