Prodrug Antiviral — CMV Prevention and Treatment (Oral) Pregnancy: Contraindicated — same as ganciclovir; mandatory contraception

Valganciclovir

Brand names: Valcyte

Adult dose

Dose: CMV induction (retinitis/disease): 900 mg twice daily × 21 days with food; CMV maintenance: 900 mg once daily with food; CMV prevention post-transplant (solid organ): 900 mg once daily × 100–200 days

Route: Oral tablet

Frequency: Twice daily (induction) or once daily (maintenance/prophylaxis)

Max: 1800 mg/day (induction)

Prodrug of ganciclovir — L-valyl ester increases oral bioavailability from 6% (ganciclovir) to 60%. Equivalent plasma exposure to IV ganciclovir 5 mg/kg. MUST be taken with food (increases AUC by 30%). Available as tablet (450 mg) and oral solution (50 mg/mL) for paediatrics. Handle as cytotoxic — do not crush tablets.

Paediatric dose

Dose: Dose (mg) = 7 × BSA × CrCl (calculated using Schwartz formula) — specialist calculation required mg (calculated)/kg

Route: Oral solution (50 mg/mL)

Frequency: Once daily (prophylaxis); twice daily (treatment)

Max: 900 mg/day (prophylaxis); 900 mg BD (treatment)

BNFc: paediatric dosing uses BSA × CrCl formula (Pescovitz equation); oral solution preferred; widely used in solid organ transplant CMV prophylaxis in children

Dose adjustments

Renal

CrCl 40–59: induction 450 mg BD, maintenance 450 mg OD; CrCl 25–39: induction 450 mg OD, maintenance 450 mg every 48 hours; CrCl 10–24: induction 450 mg every 48 hours, maintenance 450 mg twice weekly; CrCl <10: avoid

Hepatic

No dose adjustment required

Paediatric weight-based calculator

Patient weight (kg)

BNFc: paediatric dosing uses BSA × CrCl formula (Pescovitz equation); oral solution preferred; widely used in solid organ transplant CMV prophylaxis in children

Clinical pearls

PV-16000 trial: valganciclovir 900 mg OD equivalent to IV ganciclovir for CMV prevention in transplant — established oral therapy as standard of care
Renal dosing calculator essential — several online tools available; even small GFR changes significantly alter valganciclovir dosing
Do not crush tablets — cytotoxic; powder from crushed tablet can cause mucosal irritation; use oral solution for patients unable to swallow tablets
Duration of prophylaxis: 100 days for most solid organ transplants; 200 days recommended for lung transplants (higher risk)

Contraindications

ANC <500/mm³
Platelets <25,000/mm³
Hypersensitivity to valganciclovir or ganciclovir
Haemodialysis (CrCl <10 mL/min)

Side effects

Myelosuppression (neutropenia, thrombocytopaenia, anaemia)
Diarrhoea
Nausea
Headache
Insomnia
Peripheral neuropathy
Retinal detachment (CMV retinitis — disease related)

Interactions

Same as ganciclovir — see ganciclovir entry
Mycophenolate — additive myelosuppression
Zidovudine — additive myelosuppression

Monitoring

FBC weekly during treatment (neutropenia — most common reason to stop)
Renal function (dose adjustment — very sensitive)
CMV viral load (quantitative PCR)
Clinical CMV symptoms

Reference: BNFc; BNF 90; PV-16000 Trial; BHIVA Guidelines; Transplant Society (TTS) CMV Guidelines; NICE Solid Organ Transplant Guidance. Verify against your local formulary and the latest BNF before prescribing.

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways