ganciclovir

ROUTE	ONSET	PEAK	DURATION
IV	rapid	end of infusion	12–24 hr

CV: arrhythmias, edema, hypertension, hypotension

Derm: alopecia, photosensitivity, pruritus, rash, urticaria

GI: ↑liver enzymes, abdominal pain, GI BLEEDING, nausea, vomiting

GU: ↓fertility, gonadal suppression, hematuria, renal impairment

Hemat: neutropenia, THROMBOCYTOPENIA, ANEMIA, eosinophilia

Local: pain/phlebitis at IV site

Neuro: abnormal dreams, ataxia, confusion, dizziness, drowsiness, headache, malaise, nervousness, SEIZURES, tremor

Resp: dyspnea

Misc: fever

Interactions ⬆ ⬇

Drug-drug:

Toxicity may be ↑ by probenecid.
↑risk of seizures with imipenem/cilastatin; concurrent use not recommended.
Concurrent use of cyclosporine or amphotericin B↑ risk of nephrotoxicity.
↑risk of nephrotoxicity and hematological toxicity with mycophenolate mofetil.
Concurrent use with dapsone, doxorubicin, flucytosine, hydroxyurea, pentamidine, tacrolimus, trimethoprim/sulfamethoxazole, vinblastine, vincristine, or zidovudine↑ risk of nephrotoxicity and myelosuppression.

Route/Dosage ⬆ ⬇

IV (Adults and Children >3 mo): Induction: 5 mg/kg every 12 hr for 14–21 days. Maintenance regimen: 5 mg/kg/day or 6 mg/kg for 5 days of each wk. If progression occurs, ↑ to every 12 hr regimen. Prevention: 5 mg/kg every 12 hr for 7–14 days; then 5 mg/kg/day or 6 mg/kg for 5 days of each wk.
IV (Neonates ): Congenital CMV infection: 12 mg/kg/day divided every 12 hr for 6 wk.

Renal Impairment

IV (Adults and Children ): Induction: CCr 50–69 mL/min: 2.5 mg/kg/dose every 12 hr; CCr 25–49 mL/min: 2.5 mg/kg/dose every 24 hr; CCr 10–24 mL/min: 1.25 mg/kg/dose every 24 hr; CCr <10 mL/min: 1.25 mg/kg 3 times/wk after hemodialysis. Maintenance: CCr 50–69 mL/min: 2.5 mg/kg/dose every 24 hr; CCr 25–49 mL/min: 1.25 mg/kg/dose every 24 hr; CCr 10–24 mL/min: 0.625 mg/kg/dose every 24 hr; CCr <10 mL/min: 0.625 mg/kg 3 times/wk after hemodialysis.

Availability ⬆ ⬇

(Generic available)

Lyophilized powder for injection: 500 mg/vial
Solution for injection: 50 mg/mL
Premixed infusion: 500 mg/250 mL

Assessment ⬆ ⬇

Diagnosis of CMV retinitis should be determined by ophthalmoscopy before treatment with ganciclovir. Visual acuity and measurement of intraocular pressure can be done when appropriate. Follow-up ophthalmoscopy should be conducted at the end of induction (or reinduction) therapy and on a monthly basis thereafter; monthly fundus photographs can help identify early relapse. For patients who achieve immune recovery, the frequency of ophthalmic examinations may be ↓ to every 3 mo.
Culture for CMV (urine, blood, throat) may be taken before administration, but a negative CMV culture does not rule out CMV retinitis. If symptoms do not respond after several weeks, resistance to ganciclovir may have occurred.
Assess for signs of infection (fever, chills, cough, hoarseness, lower back or side pain, sore throat, difficult or painful urination). Notify health care provider if these symptoms occur.
Assess for bleeding (bleeding gums; bruising; petechiae; guaiac stools, urine, and emesis). Avoid IM injections and taking rectal temperatures. Apply pressure to venipuncture sites for 10 min.

Lab Test Considerations:

Verify negative pregnancy test prior to starting therapy.
- Monitor CBC with differential at least every 2 days during twice daily therapy and weekly thereafter. Granulocytopenia usually occurs during the first 2 wk of treatment but may occur anytime during therapy. Recovery begins within 3–7 days of discontinuation of therapy.
- Monitor renal function (BUN and serum creatinine) twice weekly during induction therapy and then at least once weekly throughout therapy.
- Monitor liver function tests (AST, ALT, serum bilirubin, alkaline phosphatase) periodically during therapy. May ↑ levels.
- Monitor serum electrolytes twice weekly during induction therapy and then at least once weekly throughout therapy.
- May ↓ blood glucose.

Implementation ⬆ ⬇

Do not administer SUBQ or IM; severe tissue irritation may result.
IV: Observe infusion site for phlebitis. Rotate infusion site to prevent phlebitis.
- Maintain adequate hydration throughout therapy.

IV Administration:

Because ganciclovir is considered to be carcinogenic, it should be handled and disposed of based on guidelines issued for antineoplastic drugs. Use double gloves and a protective gown to prepare and administer. If possible, prepare in a biologic safety cabinet or a compounding aseptic containment isolator; eye, face, and respiratory protection may be needed. Prepare and administer in a closed-system drug transfer device. During administration, if there is a potential that the substance could splash or if the patient may resist, use eye and face protection. Discard IV equipment in specially designated containers.
Intermittent Infusion: Reconstitution: Reconstitute each vial with 10 mL of sterile water for injection. Do not reconstitute with bacteriostatic water with parabens; precipitation will occur. Shake well to dissolve completely. Discard vial if particulate matter or discoloration occurs. Reconstituted solution is stable for 12 hr at room temperature; do not refrigerate. Concentration: 50 mg/mL
- Diluent: Dilute reconstituted solution or solution for injection in 100 mL of D5W, 0.9% NaCl, LR. Once diluted for infusion, solution should be used within 24 hr. Refrigerate but do not freeze.Concentration: 10 mg/mL.
Rate: Administer slowly, via infusion pump, over 1 hr using an in-line filter. Rapid administration may ↑ risk of toxicity.
Y-Site Compatibility:
- alemtuzumab
- allopurinol
- amphotericin B lipid complex
- anidulafungin
- argatroban
- arsenic trioxide
- atropine
- azithromycin
- bivalirudin
- bleomycin
- calcium chloride
- calcium gluconate
- carboplatin
- carmustine
- caspofungin
- cisplatin
- cyanocobalamin
- cyclophosphamide
- cyclosporine
- dactinomycin
- daptomycin
- defibrotide
- dexamethasone
- dexmedetomidine
- digoxin
- docetaxel
- doxorubicin liposomal
- enalaprilat
- epoetin alfa
- eptifibatide
- ertapenem
- etoposide
- etoposide phosphate
- fentanyl
- filgrastim
- fluconazole
- fluorouracil
- folic acid
- fosphenytoin
- furosemide
- glycopyrrolate
- granisetron
- heparin
- hetastarch
- hydromorphone
- ifosfamide
- indomethacin
- insulin, regular
- labetalol
- LR
- letermovir
- leucovorin
- linezolid
- lorazepam
- mannitol
- melphalan
- methotrexate
- metoprolol
- milrinone
- mitoxantrone
- nafcillin
- naloxone
- nitroglycerin
- nitroprusside
- octreotide
- oxytocin
- paclitaxel
- pamidronate
- pantoprazole
- pemetrexed
- pentobarbital
- phenobarbital
- phytonadione
- potassium chloride
- propranolol
- protamine
- remifentanil
- rituximab
- rocuronium
- sodium acetate
- sufentanil
- thiotepa
- tigecycline
- tirofiban
- trastuzumab
- vasopressin
- vinblastine
- vincristine
- voriconazole
- zoledronic acid
Y-Site Incompatibility:
- aldesleukin
- amifostine
- amikacin
- aminocaproic acid
- aminophylline
- amiodarone
- amphotericin B deoxycholate
- ampicillin
- ampicillin/sulbactam
- ascorbic acid
- atracurium
- azathioprine
- aztreonam
- benztropine
- bumetanide
- butorphanol
- cefazolin
- cefepime
- cefotaxime
- cefotetan
- cefoxitin
- ceftazidime
- ceftriaxone
- cefuroxime
- chloramphenicol
- chlorpromazine
- clindamycin
- cytarabine
- dacarbazine
- dantrolene
- daunorubicin
- dexrazoxane
- diazepam
- diazoxide
- diltiazem
- diphenhydramine
- dobutamine
- dopamine
- doxorubicin hydrochloride
- doxycycline
- ephedrine
- epinephrine
- epirubicin
- erythromycin
- esmolol
- famotidine
- fludarabine
- foscarnet
- gemcitabine
- gemtuzumab ozogamicin
- gentamicin
- haloperidol
- hydralazine
- hydrocortisone
- idarubicin
- imipenem/cilastatin
- irinotecan
- isoproterenol
- ketorolac
- levofloxacin
- lidocaine
- magnesium sulfate
- meperidine
- mesna
- methadone
- methylprednisolone
- metoclopramide
- metronidazole
- midazolam
- minocycline
- mitomycin
- morphine
- multivitamins
- mycophenolate
- nalbuphine
- nicardipine
- norepinephrine
- ondansetron
- oxacillin
- palonosetron
- papaverine
- penicillin G
- pentamidine
- phentolamine
- phenylephrine
- phenytoin
- piperacillin
- piperacillin/tazobactam
- posaconazole
- potassium acetate
- procainamide
- prochlorperazine
- promethazine
- pyridoxine
- sargramostim
- sodium bicarbonate
- succinylcholine
- tacrolimus
- theophylline
- thiamine
- tobramycin
- topotecan
- trimethoprim/sulfamethoxazole
- vancomycin
- vecuronium
- verapamil
- vinorelbine

Patient/Family Teaching ⬆ ⬇

Explain the purpose and side effects of ganciclovir. Do not stop receiving drug without consulting health care provider. If an appointment is missed, contact health care provider as soon as possible to reschedule. Advise patient to read Medication Guide before starting and periodically during therapy in case of changes.
Inform patient that ganciclovir is not a cure for CMV retinitis. Progression of retinitis may continue in immunocompromised patients during and after therapy. Advise patients to have regular ophthalmic exams at least every 6 wk. Duration of therapy for CMV prevention is based on the duration and degree of immunosuppression.
Emphasize the importance of frequent follow-up exams to monitor blood counts.
Advise patient to notify health care provider if fever; chills; sore throat; other signs of infection; bleeding gums; bruising; petechiae; or blood in urine, stool, or emesis occurs. Caution patient to avoid crowds and persons with known infections. Instruct patient to use soft toothbrush and electric razor. Patient should be cautioned not to drink alcoholic beverages or take products containing aspirin or NSAIDs.
Caution patient to use sunscreen and protective clothing to prevent photosensitivity reactions.
Advise patient to notify health care provider of all Rx or OTC medications, vitamins, or herbal products being taken and to consult with health care provider before taking other medications.
Rep: May cause fetal harm. Advise women of reproductive potential to use a nonhormonal method of contraception during therapy and for ≥30 days after last dose and to avoid breastfeeding during therapy. Advise men to use condoms during and for ≥90 days after therapy. May ↓ fertility.

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Pronunciation ⬇

Classifications ⬆ ⬇

Indications ⬆ ⬇

Action ⬆ ⬇

Pharmacokinetics ⬆ ⬇

Time/Action Profile ⬆ ⬇

Contraind./Precautions ⬆ ⬇

Adv. Reactions/Side Effects ⬆ ⬇