Subtherapeutic Exposure of Ganciclovir in Children Despite Appropriate Dosing: A Short Communication : Therapeutic Drug Monitoring

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Short Communication

Subtherapeutic Exposure of Ganciclovir in Children Despite Appropriate Dosing: A Short Communication

Marfil, Sjanene MSc*; Märtson, Anne-Grete PhD*,†; Toren-Wielema, Marlous MSc*; Leer-Buter, Coretta PhD; Schölvinck, Elisabeth H. PhD§; Alffenaar, Jan-Willem C. PhD¶,‖,**; Touw, Daan J. PhD*; Sturkenboom, Marieke G. G. PhD*

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Therapeutic Drug Monitoring 45(2):p 269-272, April 2023. | DOI: 10.1097/FTD.0000000000001050
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Ganciclovir and its oral prodrug valganciclovir are used for the prophylaxis and treatment of cytomegalovirus (CMV) infections in children.1 Despite their efficacy, these drugs can lead to severe side effects such as myelosuppression. Suboptimal exposure can lead to drug resistance and, thus, therapy failure.2–4

Therapeutic drug monitoring (TDM) is a clinical tool used to monitor drug concentrations and optimize dosing.5 TDM could help minimize unwanted effects of ganciclovir and improve efficacy, but evidence-based drug concentration targets are lacking.6 Data on the TDM of ganciclovir in children are scarce and have demonstrated varied results.7–9 Our study aimed to analyze routine ganciclovir TDM practices in pediatric patients with confirmed CMV infection.


We conducted a retrospective study on patients aged <18 years who were treated with valganciclovir for CMV infection between November 2017 and December 2020 at the University Medical Center Groningen (UMCG), Groningen, the Netherlands. The Medical Ethics Review Board of UMCG found the study to be in accordance with Dutch laws because of its retrospective nature (METc 2020/196).

Administration of valganciclovir was performed according to the “Dutch Paediatric Formulary”, based on body surface area, at 900 mg/m2/d in 2 doses and adjusted for renal function.10 The target minimum concentration (Cmin) was defined as 2–4 mg/L, and the target area under the 24-hour concentration–time curve (AUC24) was set at 80–120 mg h/L.11–15 We compared and evaluated the initial valganciclovir dosing according to the local and national pediatric dosing guidelines.10 Serum ganciclovir concentrations were collected during standard treatment and measured using a validated liquid chromatography with the tandem mass spectrometry LC-MS/MS method.16

Pharmacokinetic parameters were calculated using the population pharmacokinetic models of Nguyen et al17 and MW/Pharm++ (Prague, Czech Republic). The corresponding AUC24 was calculated for each Cmin value. If a midconcentration was obtained, the model was used to estimate both the Cmin and AUC24.

The Spearman rank correlation coefficient test was used to correlate pharmacokinetic parameters with dosing. Statistical significance was set at P < 0.05. All data were analyzed using IBM SPSS version 23 (Armonk, NY) and R version 4.0.5.


Twenty-three patients with 40 different treatment episodes of valganciclovir were included in this study. Some patients had recurrent CMV infection throughout the study period. We categorized the groups into TDM and NO TDM. The patient demographics and clinical outcomes are presented in Table 1. Sixty percent of the treatment episodes in both groups (NO TDM = 17 and TDM = 7) received an initial valganciclovir dose in accordance with the dosing guidelines (maximum of 20% deviation, considering renal function).

TABLE 1. - Baseline Demographics and Pharmacokinetic Results of Included Patients
A. Individual Patient Characteristics
Patient Characteristics Value (N = 23)
No. of male participants (%) 7 (30)
No. of patients with multiple treatment episodes 8 (35)
Age, yr 3.7 (1.4–6.4)
Weight, kg 12.1 (9.4–21.0)
Height, cm 85 (78–116)
No. of episodes per patient 1 (1–2)
Background immunodeficiency, number of occasions with (%)a
 Congenital CMV infection 2 (9)
  Allogenic stem cell 1 (4)
  Lung 2 (9)
  Liver 18 (78)
B. Characteristics of Patients Per Treatment Episode
Variable No TDM (N = 28) TDM (N = 12) P Total (N = 40)
Length of hospital stay, d 0 (0–1) 5 (1–41) 0.002 0 (0–110)
Dose valganciclovir, mg/m2/d 811 (652–958)* 720 (677–954) 0.78 805 (673–961)
Duration of therapy, d 42 (28–81) 71 (42–86) 0.17 53 (30–82)
Time to negative viral load, d 20 (13–33) 14 (4–26) 0.28 20 (11–33)§
Cmin, mg/L 0.6 (0.3–1.6)
AUC24, mg h/L 65 (47–96)
eGFR, mL/min/1.73 m2 114 (75–129) 6 (61–121) 0.07 107 (69–121)
Data are presented as median (IQR) unless denoted as frequency (%)a.
N = number of episodes,
*N = 27.
N = 11.
N = 38.
§N = 39.
AUC24, 24-hour area under the concentration–time curve; Cmin, trough concentration; CMV, cytomegalovirus; eGFR, estimated glomerular filtration rate using the Schwartz formula.

In the TDM group, 30 ganciclovir samples were collected during 12 different CMV episodes (30%). Seventy percent (21 samples) of ganciclovir Cmin was subtherapeutic (<2 mg/L). The observed median Cmin (IQR) was 0.6 (0.3–1.6) mg/L, and the median AUC24 (IQR) was 65 (47–96) mg h/L.

No correlation was observed between dosing and Cmin (P = 0.12) or AUC24 (P = 0.36). Four of the ganciclovir concentrations were in the midrange. These concentrations were extrapolated using Bayesian simulations to estimate the Cmin. Figure 1 shows individual graphs of ganciclovir Cmin and AUC24 of patients who had more than one ganciclovir level measured. These patients showed large intraindividual and interindividual variabilities in dosing and exposure. Moreover, the time of first Cmin collection in relation to the day of therapy had large variability, with a median of 7 days (IQR 5–13 days).

Individual line plots show intraindividual and interindividual variability in Cmin (A) and AUC24 (B); x-axis represents the day of sampling and y-axis (A) Cmin (mg/L); (B) AUC24 (mg h/L); BSA: Body surface area (m2); colors indicate valganciclovir dose administered 24 hours before sampling. Red dashed lines represent lower and upper target concentrations (A) or AUC24 (B).


Overall, our findings suggest that, despite dosing according to the guidelines, pediatric patients are unlikely to achieve optimal drug exposure.7,9 However, the optimal drug exposure has not yet been defined for ganciclovir in adults or children. When compared with adults, Luck et al found that children tended to achieve lower ganciclovir Cmin than adults, possibly due to better renal function.6 In that study, a significant number of Cmin levels in pediatrics were lower than 0.5 mg/L with a risk of ganciclovir resistance and possible treatment failure. Moreover, the suboptimal drug exposure observed in this study is in line with earlier reports where, at most, 30% of the study subjects achieved targeted drug exposure.12,18,19

We observed decreasing viral loads (median 14 days to negative viral load), although most of the simulated AUC24 values were lower than the target exposure. Our finding is in line with the findings of Launay et al,8 where 8 of 10 subjects achieved undetectable viremia with a median AUC24 of 35 mg h/L (range, 21–84). In general, the immune system plays an important role in viral clearance. Thus, in some patients with a recovering immune system, a response can be expected without treatment.20 However, this was not investigated in this study.

The limitations of this study were its retrospective nature, a small number of participants, and infrequent monitoring of ganciclovir concentrations and CMV viral load. We also used a dosing approach different from that used in previous studies, which makes it difficult to compare the results.21,22 It is possible that the lower concentrations can be explained by the lower dosages used in this study, although an additional study with a different dosing approach is required to confirm this.


Our results showed large intravariability and intervariability in pharmacokinetics. As most patients receive the standard recommended dose, TDM can be beneficial in reducing the variability in ganciclovir concentrations. Although the lower exposure did not result in treatment failure in our study, this does not imply that the concentrations were optimal. Another small study demonstrated a slow decline in viral load at currently used dosages.6 Clearly, there is a need for evidence-based target concentrations for CMV treatment to guide dosing that maximizes viral load reduction without increasing toxicity. Evaluation of an in vitro pharmacokinetic/pharmacodynamic (PK/PD) target in a larger population-based prospective study including frequent PK and virological sampling may aid in exploring the benefits of TDM in children. Moreover, monitoring AUC24 is recommended, as it has been reported to be a good indicator of efficacy and toxicity in pediatric patients.23,24 This may be beneficial for individual treatment.

This study does not provide a final answer on the value of TDM of ganciclovir, but it raises an important concern about the large intraindividual and interindividual variability in drug exposure, resulting in potential suboptimal treatment in some children.


1. Kotton CN, Kumar D, Caliendo AM, et al. Updated international consensus guidelines on the management of cytomegalovirus in solid-organ transplantation. Transplantation. 2013;96:333–360.
2. Paya C, Humar A, Dominguez E, et al. Efficacy and safety of valganciclovir vs. oral ganciclovir for prevention of cytomegalovirus disease in solid organ transplant recipients. Am J Transpl. 2004;4:611–620.
3. Takahata M, Hashino S, Nishio M, et al. Occurrence of adverse events caused by valganciclovir as pre-emptive therapy for cytomegalovirus infection after allogeneic stem cell transplantation is reduced by low-dose administration. Transpl Infect Dis. 2015;17:810–815.
4. Humar A, Lebranchu Y, Vincenti F, et al. The efficacy and safety of 200 days valganciclovir cytomegalovirus prophylaxis in high-risk kidney transplant recipients. Amer J Transpl. 2010;10:1228–1237.
5. Märtson A-G, Edwina AE, Kim HY, et al. Therapeutic drug monitoring of ganciclovir: where are we? Ther Drug Monit. 2022;44:138.
6. Märtson A-G, Sturkenboom MG, Knoester M, et al. Standard ganciclovir dosing results in slow decline of cytomegalovirus viral loads. J Antimicrob Chemother. 2022;77:466–473.
7. Luck S, Lovering A, Griffiths P, et al. Ganciclovir treatment in children: evidence of subtherapeutic levels. Int J Antimicrob Agents. 2011;37:445–448.
8. Launay E, Théôret Y, Litalien C, et al. Pharmacokinetic profile of valganciclovir in pediatric transplant recipients. Pediatr Infect Dis J. 2012;31:405–407.
9. Vethamuthu J, Feber J, Chretien A, et al. Unexpectedly high inter- and intrapatient variability of Ganciclovir levels in children. Pediatr Transpl. 2007;11:301–305.
10. Geneesmiddel. Valganciclovir | Kinderformularium. Available at: Accessed August 10, 2022.
11. Facchin A, Elie V, Benyoub N, et al. Population pharmacokinetics of ganciclovir after valganciclovir treatment in children with renal transplant. Antimicrob Agents Chemother. 2019;63:e1922–e1219.
12. Åsberg A, Bjerre A, Neely M. New algorithm for valganciclovir dosing in pediatric solid organ transplant recipients. Pediatr Transpl. 2013;18:103–111.
13. Stockmann C, Roberts JK, Knackstedt ED, et al. Clinical pharmacokinetics and pharmacodynamics of ganciclovir and valganciclovir in children with cytomegalovirus infection. Expert Opin Drug Metab Toxicol. 2014;11:205–219.
14. Available at: Accessed June 3, 2021.
15. Märtson AG, Edwina AE, Burgerhof JGM, et al. Ganciclovir therapeutic drug monitoring in transplant recipients. J Antimicrob Chemother. 2021;76:2356–2363.
16. Märtson A, van Hateren K, van den Bosch G, et al. Determination of ganciclovir and acyclovir in human serum using liquid chromatography-tandem mass spectrometry. J Appl Bioanal. 2018;4:175–186.
17. Nguyen T, Oualha M, Briand C, et al. Population Pharmacokinetics of intravenous Ganciclovir and oral Valganciclovir in pediatric population to optimize dosing regimens. Antimicrob Agents Chemother. 2021;65:e2320–e2544.
18. Villeneuve D, Brothers A, Harvey E, et al. Valganciclovir dosing using area under the curve calculations in pediatric solid organ transplant recipients. Pediatr Transpl. 2013;17:80–85.
19. Peled O, Berkovitch M, Rom E, et al. Valganciclovir dosing for cytomegalovirus prophylaxis in pediatric solid-organ transplant recipients: a prospective pharmacokinetic study. Pediatrinfect Dis J. 2017;36:745–750.
20. Harari A, Zimmerli SC, Pantaleo G. Cytomegalovirus (CMV)-specific cellular immune responses. Hum Immunol. 2004;65:500–506.
21. Vaudry W, Ettenger R, Jara P, et al. Valganciclovir dosing according to body surface area and renal function in pediatric solid organ transplant recipients. Am J Transplant. 2009;9:636–643.
22. Pescovitz MD, Ettenger RB, Strife CF, et al. Pharmacokinetics of oral valganciclovir solution and intravenous ganciclovir in pediatric renal and liver transplant recipients. Transpl Infect Dis. 2009;12:195–203.
23. Franck B, Autmizguine J, Marquet P, et al. Pharmacokinetics, pharmacodynamics, and therapeutic drug monitoring of valganciclovir and ganciclovir in transplantation. Clin Pharmacol Ther. 2022;112:233–276.
24. Wiltshire H, Paya Cv, Pescovitz MD, et al. Pharmacodynamics of oral ganciclovir and valganciclovir in solid organ transplant recipients. Transplantation. 2005;79:1477–1483.

ganciclovir; valganciclovir; therapeutic drug monitoring; cytomegalovirus

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the International Association of Therapeutic Drug Monitoring and Clinical Toxicology.