Guideline for Cidofovir

Cidofovir is a nucleoside DNA polymerase inhibitor with activity against herpes viruses,
varicellar-zoster virus, cytomegalovirus (CMV), Epstein-Barr virus, adenovirus, human
papillomavirus and human polyomavirus. It suppresses viral replication by selective
inhibition of DNA synthesis (HSV-1, HSV-2 adenovirus and CMV DNA thought to be
inhibited). Patients receiving cidofovir require pre-hydration and probenecid to minimise
nephrotoxicity.

Indications
Adenovirus
First line treatment of adenovirus infection in immunocompromised patients:
 who are PCR +ve for adenovirus and active treatment is required

CMV
Second line treatment for CMV
 who are PCR +ve for CMV and who have absent or non-functioning T cells, where therapies
with ganciclovir and foscarnet, or a combination of these two have failed: i.e. increasing viral
load or onset of clinical symptoms despite treatment

BK virus haemorrhagic cystitis

 Evidence on the use of cidofovir for BK virus haemorrhagic cystitis is limited. A less nephrotoxic
and potentially safer option is oral ciprofloxacin.

Preparation
• Cidofovir is prepared by the oncology pharmacy. Liaise with the paediatric pharmacist and
fax prescription to ext 5914 (Oncology pharmacy)
• Contact oncall pharmacist outside of normal pharmacy opening hours if urgent
• Available as 375mg/5ml injection for IV infusion (Section 29)

Dose and administration for adenovirus and CMV

For patients with normal renal function:
• Induction: 5mg/kg once a week for two weeks
• Maintenance: 5mg/kg every two weeks according to response until two consecutive negative
results
Decision to proceed to maintenance and stop therapy is made by the Paediatric Hematologist
depending on adenovirus status. Maintenance therapy should be charted only when the most recent
adenovirus PCR results are known.

For renally compromised patients:

• Induction: 1mg/kg 3 times a week for 2 weeks
• Maintenance: 1mg/kg every two weeks according to response until two consecutive negative
results
Decision to proceed to maintenance and stop therapy is made by Paediatric Hematologist
depending on adenovirus status. Maintenance therapy should be charted when adenovirus status is
known.

Administration
• Safe handling precautions are required when diluting and administering cidofovir
 Infuse dose in 100mL sodium chloride 0.9% over one hour.
 Use 50 mL of sodium chloride 0.9% if patient less than 10 kg
 For fluid restricted patients cidofovir can be made as 7.5mg/mL syringes- discuss with
paediatric pharmacist

Administration of cidofovir should be accompanied by concomitant intravenous hydration and oral

probenecid as below.

Page 1 of 2
Written and Approved by: Pharmacy Department and Paediatric Haematology and Oncology
May 2013
 Guideline for Cidofovir

Hydration
• Must be given to minimise nephrotoxicity
• Hydration with sodium chloride 0.9% should be given at 15ml/kg for one hour pre and
for one hour post cidofovir
• If patient is fluid restricted in intensive care (PICU) the fluid protocol may need to be
individualized

Probenecid
Concomitant oral probenecid is thought to reduce the incidence and severity of
cidofovir related nephrotoxicity. It is thought that cidofovir becomes concentrated in
the proximal renal tubules and causes degeneration and necrosis of these cells.
Probenecid is thought to compete for uptake at the proximal tubule site thus
minimising cidofovir uptake and consequently limiting nephrotoxicity.

Oral probenecid dose

Probenecid Dose
3 hours pre 2 hours post end of 8 hours post end of
Weight (kg) cidofovir infusion cidofovir infusion cidofovir infusion
<20 500mg orally 250mg orally 250mg orally
21 – 40 1 gram orally 500mg orally 500mg orally
41- 60 1.5gram orally 750mg orally 750mg orally
>60 2gram orally 1gram orally 1gram orally

 Probenecid tablets are supplied from inpatient pharmacy/dispensary. Please fax/scan

prescription to dispensary to order.
 Tablets may be crushed and dispersed in water.
 May be given with food to decrease nausea.

Monitoring and drug interactions

• Renal damage is a major therapy limiting toxicity related to cidofovir.

• Urea and electrolytes must be closely monitored for the duration of therapy
• Consider stopping concurrent nephrotoxic drugs including aciclovir.
• Probenecid may affect the metabolism and tubular secretion of other drugs
e.g. acyclovir, methotrexate and penicillin based antibiotics
Discuss potential drug interactions with paediatric pharmacist

Reference:
 Great Ormond Street Hospital. Antibiotic guidelines. 2001
 Lexicomp Paediatric Dosage Handbook 17th Edition 2010
 Matthes-Martin et al: Adenovirus infection in leukemia and HSCT. Transplant Infectious Disease
2012: 14: 555–563

Page 2 of 2
Written and Approved by: Pharmacy Department and Paediatric Haematology and Oncology
May 2013