Discontinuation of Anticytomegalovirus Therapy in Patients with HIV Infection and Cytomegalovirus Retinitis

Publication Type
Journal Article
Year of Publication
1999
Authors
Whitcup, SM; Fortin, E; Lindblad, AS; Griffiths, P; Metcalf, JA; Robinson, MR; Manischewitz, J; Baird, B; Perry, C; Kidd, IM; Vrabec, T; Davey, RT; Falloon, J; Walker, RE; Kovacs, JA; Lane, HC; Nussenblatt, RB; Smith, J; Masur, H; Polis, MA
Secondary
JAMA
Volume
282
Start Page
1633
Pagination
1633-1637
Date Published
11/1999
Keywords
Anti-HIV Agents; Antiviral Agents; Antiviral Agents/therapeutic use; CD4 Lymphocyte Count; Cytomegalovirus Retinitis/diagnosis; Cytomegalovirus Retinitis/drug therapy; Cytomegalovirus/isolation & purification; Disease Progression
Abstract

CONTEXT:

Persons with cytomegalovirus (CMV) retinitis and acquired immunodeficiency syndrome (AIDS) have required lifelong anti-CMV therapy to prevent the progression of retinal disease and subsequent loss of vision.

OBJECTIVE:

To determine whether patients who were taking highly active antiretroviral therapy (HAART) and who had stable CMV retinitis could safely discontinue anti-CMV therapy without reactivation of their retinitis or increase in human immunodeficiency virus (HIV) viral load.

DESIGN:

Prospective nonrandomized interventional trial performed from July 1997 to August 1999.

SETTING:

Clinical Center of the National Institutes of Health, Bethesda, Md.

PATIENTS:

Fourteen patients with stable CMV retinitis and HIV infection and CD4+ cell counts higher than 0.1 5 x 10(9)/L and being treated with systemic anti-CMV medications and HAART.

INTERVENTIONS:

Discontinuation of specific anti-CMV therapy.

MAIN OUTCOME MEASURES:

Reactivation of CMV retinitis, development of extraocular CMV infection, detection of CMV in blood and urine, HIV burden, immunologic function, quality of life, morbidity, and mortality.

RESULTS:

Twelve (89.7%) of 14 patients had evidence of immune recovery uveitis before anti-CMV drugs were discontinued. No patient had reactivation of CMV retinitis or development of extraocular CMV disease during mean follow-up of 16.4 months (range, 8.3-22.0 months) without anti-CMV therapy. Human immunodeficiency viral load remained stable following cessation of anti-CMV medications. Blood and urine assays for CMV were briefly positive in 9 patients but did not predict reactivation of CMV disease. Worsening immune recovery uveitis was associated with a substantial (>3 lines) vision loss in 3 patients.

CONCLUSIONS:

Maintenance anti-CMV medications were safely stopped in those patients who had stable CMV retinitis and elevated CD4+ cell counts and who were taking HAART. The study demonstrates that immune recovery following potent antiretroviral therapy is effective in controlling a major opportunistic infection, even in patients with a history of severe immunosuppression.