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How long should someone take acyclovir post ASCT? Or should the question be about the risks vs. benefits as the months pass after you have an ASCT?
Some oncologists recommend acyclovir post ASCT for 12 months. I know a world-renown MM specialist that recommends acyclovir post ASCT for three years. Yikes!
What are the benefits of myeloma patients taking acyclovir after their ASCT?
Reduced Risk of Herpes Zoster Reactivation: After ASCT, myeloma patients are particularly susceptible to shingles due to immune suppression. Acyclovir helps prevent the reactivation of the varicella-zoster virus (VZV), which causes shingles, significantly lowering the risk of outbreaks.
Reduced Risk of Complications from Infections: Shingles can lead to complications, including postherpetic neuralgia (long-term nerve pain) and, in severe cases, disseminated herpes zoster, which can spread to internal organs. Preventing shingles reduces these risks, which is especially important for patients with already compromised health.
Improved Quality of Life: Shingles and related complications can cause severe pain and discomfort. By preventing these infections, acyclovir helps improve patients’ quality of life during the vulnerable post-transplant period.
Reduced Hospitalization and Healthcare Costs: By lowering the likelihood of infection, acyclovir may reduce hospital admissions and associated healthcare costs related to treating infections and complications in post-ASCT patients.
What are the risks of myeloma patients taking acyclovir after their ASCT?
1. Renal Toxicity
Acyclovir can cause kidney issues, especially if the patient is dehydrated or has preexisting renal impairment, which is relatively common in multiple myeloma patients. In myeloma, kidney function may already be compromised, so careful monitoring is required to prevent further nephrotoxicity.
2. Bone Marrow Suppression
Although rare, acyclovir can contribute to bone marrow suppression, potentially worsening cytopenias in patients post-ASCT, who are already at risk for low blood cell counts. This can delay recovery and increase infection risk.
3. Neurotoxicity
Acyclovir can lead to neurotoxicity, particularly in patients with impaired renal function. Symptoms may include confusion, hallucinations, and seizures. Given the potential kidney issues in myeloma patients, neurotoxic effects could present even at standard doses if drug clearance is reduced.
4. Drug Interactions
Myeloma patients are often on multiple medications, including other antivirals, antifungals, and chemotherapy agents, increasing the risk of drug interactions. Acyclovir, especially at high doses, can interact with other drugs affecting kidney function or bone marrow.
5. Dehydration and Electrolyte Imbalance
Acyclovir requires adequate hydration to prevent crystallization in the kidneys, a condition that can cause kidney damage. Dehydration is a concern, particularly for myeloma patients with gastrointestinal symptoms post-ASCT.
Acyclovir and Infection for Myeloma Patients-
Each MM patient decides for themselves what risks he/she takes. However, according to the first study linked below, the risk of a shingles outbreak post ASCT drops dramatically after 12 months.
I imagine that the risk of side effects from acyclovir can increase after 12 months as well. My thinking then, is that 12 months of acyclovir post ASCT is a good balance of risks and benefits.
“Background: Herpes zoster (HZ) is a frequent complication after autologous stem cell transplantation (ASCT). The option of zoster prophylaxis with an antiviral drug is described in the literature, but there is no consensus on the drug and the dosage.
Patients and methods: We analyzed the records of 310 patients treated with ASCT who were controlled regularly regarding HZ inter alia for at least 24 months following ASCT. Since 01/2015 patients received prophylactic low-dose acyclovir (400 mg per day) during the first 12 months following discharge after ASCT (n = 107).
Results: Twenty percent of patients without this kind of prophylaxis and 2.8% of patients with prophylaxis developed HZ (p < .001). No patient with this prophylaxis developed HZ in the first year after ASCT, 2.8% of patients in the second year after ASCT.
A prognostic factor was the kind of diagnosis: 30% of lymphoma patients and 14% of myeloma patients developed HZ in the first 24 months after ASCT without prophylaxis, but only 6.3% and 0% of patients with prophylaxis, respectively. Neither an increase of HZ cases following prophylaxis nor acyclovir refractory HZ cases were observed.
Conclusions: Zoster prophylaxis with low-dose acyclovir over 12 months after ASCT is effective and well tolerated.”
“Acyclovir is an antiviral drug that slows the growth and spread of the herpes virus in the body. It may be used to treat herpes infections such as:
Chickenpox
Cold sores
Genital herpes
Shingles.
Acyclovir can be given orally (by mouth) or as an injection…
What are the more common side effects of acyclovir?
Acyclovir is usually well-tolerated, and most side effects are mild. Examples of commonly reported side effects with oral acyclovir include:
Diarrhea
Headache
Itching
Mild skin pain
Mouth pain (if using an acyclovir buccal tablet)
Nausea
Rash
Vomiting
Examples of commonly reported side effects with injectable acyclovir include:
Nausea
Redness or inflammation around the injection site
Vomiting…
What are some mild side effects of acyclovir?
Acyclovir may cause mild side effects. Examples of mild side effects reported with acyclovir include:
Diarrhea
Difficulty sleeping
Dizziness
Fatigue (lacking in energy) or feeling tired
Fever
Flushing or skin redness or unusually warm skin
Headache
Itching
Loss of appetite
Menstrual abnormalities
Mild skin pain
Mouth or gum pain (if using an acyclovir buccal tablet)
Mouth ulcers (Canker sores) or other sores in the mouth
Muscle or leg pain
Nausea
Rash
Sleepiness
Sore throat
Stomach pain
Sweating
Taste disturbances
Thirst
Urticaria (hives)
Vomiting
What are some serious side effects of acyclovir?
Serious side effects may occur rarely with acyclovir. Examples of these serious side effects that have been reported with acyclovir include:
Blood in the urine (hematuria)
Chest pain or palpitations
Decreases in red or white blood cells or changes to the way the blood clots
Hair loss (alopecia)
Increases in laboratory test results for blood urea nitrogen or creatinine
Kidney problems, such as decreases in how often you urinate or pain during urination, pain in the kidneys, problems with the functioning of your kidneys (renal impairment), crystals in your urine (crystalluria), or your kidneys stop working (acute renal failure)
Liver enzyme changes, increases in bilirubin, or liver inflammation
Low blood pressure
Lymph node swelling
Mental health changes such as agitation or aggression, confusion, depression, hallucinations, psychotic symptoms
Problems with the nervous system (ataxia)
Seizures or convulsions
Serious skin reactions such as Stevens-Johnson syndrome or toxic epidermal necrolysis
Serious allergic reactions, such as angioedema or anaphylaxis
Severe reactions following an acyclovir injection such as tissue death (tissue necrosis)
Shortness of breath
Speech disturbances
Swelling in the lower legs, ankles, or feet (peripheral edema)
Tremors
Unconsciousness (coma) or brain damage (extremely rare)
Vision changes or eye inflammation (Pars planitis)