*Purpose: Although only approved for primary prophylaxis of CMV among allogeneic stem cell transplant recipients, there is great interest in the use of letermovir (LET) among solid organ transplant (SOT) recipients with drug resistant CMV due to toxicity of alternative agents and novel mechanism of action. We sought to describe our experience with LET for SOT recipients.

*Methods: All adult SOT recipients with of drug resistant CMV who received LET in 2018 for treatment or secondary prophylaxis were evaluated. Patient and CMV characteristics as well as outcomes were obtained.

*Results: Nine SOT recipients received LET for drug resistant CMV. Five received LET 720 mg daily for treatment of active infection and four received LET 480 mg daily for secondary prophylaxis. At both doses, LET was well tolerated and without significant bone marrow suppression, hepatotoxicity or nephrotoxicity. Among the patients on treatment dose, two achieved undetectable CMV PCR (<35 IU/mL) and two achieved a reduction in CMV PCR to a persistently low level (< 500 IU/mL). One patient (C) had ganciclovir added at 21 days. No patients developed new or worsening tissue invasive disease after LET was initiated. One recipient on secondary prophylaxis experienced breakthrough viremia during week 2.

*Conclusions: LET for treatment or secondary prophylaxis among SOT recipients appears to be safe and possibly effective in this ongoing cohort study. Given the urgent need for well tolerated effective treatment for resistant CMV in SOT recipients, LET and combination therapies should be studied.

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