Treatment of Cytomegalovirus (CMV) Esophagitis
For CMV esophagitis, intravenous ganciclovir or foscarnet for 21-28 days is the recommended treatment until signs and symptoms have resolved. 1
First-line Treatment Options
Severe Symptoms (Unable to Take Oral Medications)
- Intravenous ganciclovir: 5 mg/kg IV twice daily for 21-28 days (BII) 1
- Intravenous foscarnet: 60 mg/kg IV every 8 hours or 90 mg/kg IV every 12 hours for 21-28 days (BII) 1, 2
Mild to Moderate Symptoms (Able to Take Oral Medications)
- Oral valganciclovir: 900 mg twice daily for 21-28 days (BII) 1, 3
- Only appropriate if symptoms are not severe enough to interfere with oral absorption
Treatment Efficacy
- Clinical response rates to ganciclovir therapy are approximately 75-77% 4, 2
- Foscarnet and ganciclovir have shown similar efficacy in controlled trials specifically for CMV esophagitis:
- 73% endoscopic improvement with foscarnet
- 70% endoscopic improvement with ganciclovir 2
Monitoring During Treatment
- Complete blood counts and serum electrolytes should be monitored twice weekly during induction therapy and once weekly thereafter (AIII) 1
- Renal function should be monitored regularly, especially with foscarnet therapy 1, 3
- Endoscopy may be repeated at the end of therapy to confirm healing 2
Adverse Effects to Monitor
- Ganciclovir/Valganciclovir: Neutropenia, thrombocytopenia, anemia, renal dysfunction 1, 3
- Foscarnet: Nephrotoxicity, electrolyte abnormalities (particularly calcium and phosphate), seizures, neurologic dysfunction 1, 3
Special Considerations
HIV-Infected Patients
- Initiate or optimize antiretroviral therapy (ART) concurrently with CMV treatment (BIII) 1
- No data suggest that starting ART would worsen CMV gastrointestinal disease 1
Immunosuppressed Non-HIV Patients
- CMV esophagitis can occur in patients receiving immunosuppressive therapy, particularly high-dose glucocorticoids 5, 6
- Treatment approach should include attempts to decrease immunosuppression whenever possible 1
Relapse Risk and Maintenance Therapy
- Without maintenance therapy, relapse rates of approximately 39-47% have been reported 4, 7
- Median time to relapse is approximately 4-9 weeks after completing induction therapy 4, 7
- For patients with HIV, maintenance therapy should be considered until immune recovery occurs (CD4+ count >100 cells/μL for 3-6 months) 1
Treatment Failures
- For patients who fail to respond to ganciclovir, foscarnet is an effective alternative 4
- For severe or refractory cases, combination therapy with ganciclovir and foscarnet may be considered, though this approach carries substantial risk of adverse effects 1
Important Caveats
- Diagnosis of CMV esophagitis requires endoscopic visualization of ulcers plus histopathologic confirmation of CMV inclusions 1
- Culturing CMV from esophageal tissue alone is insufficient for diagnosis, as some immunocompromised patients may have positive cultures without clinical disease 1
- Treatment should not be delayed as prompt initiation of therapy is associated with better outcomes 1