The current role of maribavir for treatment of cytomegalovirus in transplant recipients.

Introduction: Cytomegalovirus (CMV) is one of the most common infections after solid organ or hematopoietic stem cell transplantation. Typically, ganciclovir or valganciclovir have been used for first-line therapy, with foscarnet and cidofovir being used for resistant or refractory infections. Maribavir was recently approved as a novel CMV therapeutic for transplant recipients.

Areas covered: We examine published studies of maribavir for posttransplant cytomegalovirus infection and summarize the current understanding of its pharmacology, clinical efficacy, toxicity, and risk of treatment-emergent resistance.

Expert opinion: Maribavir is generally the preferred therapy for CMV infection that is resistant or refractory to valganciclovir/ganciclovir treatment or transplant recipients who are intolerant of first-line treatment. It is well-tolerated overall without significant myelosuppression or nephrotoxicity, a stark difference from traditional CMV antivirals. However, there are high rates of treatment-emergent maribavir resistance, particularly among patients with high baseline CMV viral loads. Some UL97 mutations impart resistance to both maribavir and ganciclovir, though high-grade cross-resistance is rare. Transplant recipients who receive maribavir require close monitoring as resistance can develop even after an initial therapeutic response. Maribavir is an effective and well-tolerated addition to the CMV armamentarium, though it has important caveats that require consideration by infectious disease and transplant practitioners.