Vitreous Penetration of Orally Administered Valacyclovir

TONY H. HUYNH, MARK W. JOHNSON, GRANT M. COMER, AND DOUGLAS N. FISH To investigate the vitreous penetration of acyclovir, the active metabolite of valacyclovir, after oral administration of valacyclovir. DESIGN: Prospective, interventional case series. METHODS: Ten patients scheduled for elective pars plana vitrectomy at a single academic institution were given three oral doses of valacyclovir 1000 mg eight hours apart the day before surgery, with a fourth dose on the morning of surgery. Blood and undiluted vitreous samples were obtained during surgery and subsequently were analyzed with high-performance liquid chromatography to determine the concentrations of acyclovir present. RESULTS: Ten eyes of 10 subjects ranging in age from 46 to 83 years were included. All patients had normal renal and hepatic function as conrmed by metabolic panels obtained before surgery. Mean serum acyclovir concentration standard deviation was 4.41 0.88 g/ml (range, 3.18 to 5.92 g/ml), mean vitreous acyclovir concentration was 1.03 0.23 g/ml (range, 0.67 to 1.33 g/ml), and mean vitreous-to-serum concentration ratio of acyclovir was 0.24 0.06 (range, 0.16 to 0.34). CONCLUSIONS: Orally administered valacyclovir results in substantial vitreous penetration of acyclovir. The vitreous concentrations achieved in noninamed eyes are within the reported inhibitory ranges for most strains of herpes simplex 1, herpes simplex 2, and varicella zoster virus. This suggests that orally administered valacyclovir may be an alternative to intravenous acyclovir in the treatment of acute retinal necrosis. (Am J Ophthalmol 2008;145:682 686. 2008 by Elsevier Inc. All rights reserved.)
PURPOSE:

Today, ARN is recognized as an infectious retinitis characterized by one or more foci of retinal necrosis with discrete borders in the fundus periphery, rapid circumferential progression of disease, evidence of occlusive retinal arteritis, and a prominent inammatory reaction in the vitreous and anterior chamber.3 The usual etiologic agents are believed to be varicella zoster virus (VZV), herpes simplex virus 1 (HSV-1), and herpes simplex virus 2 (HSV-2). Evidence of causative roles for cytomegalovirus and Epstein-Barr virus in this condition is limited.4,5 Current standard treatment of ARN consists of intravenous acyclovir (10 mg/kg every eighth hour or 1500 mg/m2 daily) for ve to 10 days followed by oral acyclovir 800 mg ve times daily for six weeks, prophylactic laser demarcation, and possible adjunctive therapy with aspirin and corticosteroids.6 However, the inconvenience and costs associated with administration of intravenous acyclovir have spawned interest in the use of newer oral antiviral agents, such as valacyclovir and famciclovir, as primary treatment for ARN. Aslanides and associates reported successful treatment in three cases of ARN with oral valacyclovir in 2002.7 More recently, Aizman and associates and Emerson and associates reported their results in treating ARN with oral antiviral therapy without intravenous acyclovir.8,9 Although these reports have demonstrated successful clinical outcomes with oral antiviral therapy in patients with ARN, little is known about the ocular penetration of these antiviral agents in human eyes. To our knowledge, no published studies have reported the direct measurement of vitreous acyclovir concentrations after oral valacyclovir. We examined the vitreous penetration of orally administered valacyclovir to understand further the role of this drug in the primary treatment of ARN.

scribed in six patients by Urayama and associates in 1971.1 The cause of this condition was not well understood until more than a decade later, when Culbertson and associates rst provided histologic evidence for herpes virus particles in the retina of an affected eye.2
Accepted for publication Nov 16, 2007. From the W. K. Kellogg Eye Center, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan (T.H.H., M.W.J., G.M.C.); and the Department of Clinical Pharmacy, University of Colorado Health Sciences Center, Denver, Colorado (D.N.F.). Inquiries to Mark W. Johnson, W. K. Kellogg Eye Center, 1000 Wall Street, Ann Arbor, MI 48105; e-mail: markwj@umich.edu

CUTE RETINAL NECROSIS (ARN) WAS FIRST DE-

METHODS
TEN PATIENTS SCHEDULED FOR ELECTIVE PARS PLANA VIT-

rectomy were enrolled in the study. Exclusion criteria included hypersensitivity to valacyclovir or acyclovir, current pregnancy or breast feeding, renal or hepatic disease (as conrmed by history and metabolic panels), infection with human immunodeciency virus, history of bone marrow or renal transplantation, history of any antiviral therapy within one month of surgery, history of probenecid or cimetidine use within one month of surgery, previous
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TABLE 1. Subject Characteristics, Indications for Surgery, and Specimen Collection Times from the Last Dose of Valacyclovir
Time to Blood Sample Collection (hrs) Time to Vitreous Sample Collection (hrs)

Subject No.

Age (yrs)

Gender

Eye

Indications for Surgery

1 2 3 4 5 6 7 8 9 10 MeanSD

77 73 68 83 46 52 57 65 62 78

M F M M F F F F F M

Left Left Right Left Left Right Right Left Left Left

Macular hole Macular hole Epiretinal membrane Epiretinal membrane Macular schisis Vitreous opacities Macular hole Macular hole Macular hole Macular hole

3.25 2.42 2.10 4.17 2.25 1.50 2.67 1.50 2.33 2.00 2.42 0.80

3.87 3.13 2.50 4.72 2.75 2.75 3.25 2.32 2.88 2.93 3.11 0.71

F female; M male; SD standard deviation.

TABLE 2. Serum and Vitreous Acyclovir Concentrations after the Administration of Oral Valacyclovir
Subject No. Serum 1 (g/ml) Serum 2 (g/ml) Mean Serum (g/ml) Vitreous (g/ml) Vitreous-to-Serum Ratio

1 2 3 4 5 6 7 8 9 10 MeanSD

4.45 3.98 4.76 5.22 4.27 3.61 5.92 3.21 3.43 5.28 4.41 0.89

4.38 4.02 4.80 5.19 4.22 3.70 5.86 3.18 3.41 5.27 4.40 0.87

4.42 4.00 4.78 5.21 4.25 3.66 5.89 3.20 3.42 5.28 4.41 0.88

1.14 0.84 1.33 0.90 1.16 1.24 1.30 0.88 0.67 0.87 1.03 0.23

0.26 0.21 0.28 0.17 0.27 0.34 0.22 0.28 0.20 0.16 0.24 0.06

SD standard deviation.

vitrectomy, vitreous hemorrhage within one month of scheduled surgery, active uveitis or vasculitis, endophthalmitis, and rhegmatogenous retinal detachment. All patients were instructed to take three 1000-mg doses of valacyclovir eight hours apart the day before surgery with an additional dose on the morning of surgery. Log sheets were given to the participants to record the time at which they took each dose. Just before surgery, before infusion of any intravenous solutions, two 5-ml samples of venous blood were collected (two samples were collected from each patient to conrm the precision of the highperformance liquid chromatography [HPLC] assay). At the beginning of the vitrectomy procedure, 1 ml undiluted vitreous was obtained with the vitreous cutter, taking care to avoid sampling any vitreous contaminated by blood from sclerotomy sites. Collection times of all samples were recorded. After the blood samples were allowed to clot, they were centrifuged and the serum was collected. Serum VOL. 145, NO. 4

and vitreous samples then were frozen and stored at 70 C until analysis. Serum and vitreous samples were analyzed for valacyclovir and acyclovir concentrations using validated HPLC assays. Valacyclovir and acyclovir samples were prepared for HPLC analysis by extraction in methanol through a C18 solid phase extraction column, evaporation to dryness under nitrogen gas, reconstitution in 5.0 mM aqueous sodium acetate mobile phase solution, and centrifugation. Aliquots of prepared samples then were injected into the HPLC system for drug assay. Chromatographic conditions included ultraviolet detection at a wavelength of 254 nm, ambient room temperature, and mobile phase ow rates of 3.0 ml/minute. The mobile phase consisted of 5.0 mM aqueous sodium acetate and acetonitrile (99:1) adjusted to a pH of 3.0 for determination of valacyclovir concentrations; the mobile phase for the acyclovir assay was similar except for the omission of acetonitrile. Assay of both drugs
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used guanosine as the internal standard. Validation of assay methods was performed before assay of study samples. Five-point standard curves were constructed for both drugs on each validation and study day. Standard curves were linear over the range of 0.0 to 100 g/ml of valacyclovir and acyclovir (mean, r2 0.997 for valacyclovir and 0.998 for acyclovir). The within-day and between-day coefcients of variation for valacyclovir and acyclovir assays were 1.6% and 2.3%, respectively.

RESULTS
TEN EYES OF THE 10 ENROLLED SUBJECTS WERE INCLUDED IN

the study. Mean patient age was 66.1 years (range, 46 to 83 years; Table 1). Six eyes underwent pars plana vitrectomy for macular hole, two for epiretinal membrane, one for vitreous opacities, and one for myopic macular schisis. The mean time standard deviation (SD) from the last valacyclovir dose to collection of the serum samples was 2.42 0.80 hours (range, 1.50 to 4.17 hours), whereas the mean time SD from last valacyclovir dose to collection of the vitreous sample was 3.11 0.71 hours (range, 2.32 to 4.72 hours; Table 1). No detectable valacyclovir levels were found in any serum or vitreous specimens. The mean SD serum acyclovir concentration was 4.41 0.89 g/ml (range, 3.21 to 5.92 g/ml) for the rst set of serum samples and 4.40 0.87 g/ml (range, 3.18 to 5.86 g/ml) for the second set (Table 2). The overall mean SD serum acyclovir level was 4.41 0.88 g/ml (range, 3.18 to 5.92 g/ml). The mean SD vitreous acyclovir concentration was 1.03 0.23 g/ml (range, 0.67 to 1.33 g/ml), and the mean SD vitreous-to-serum acyclovir concentration ratio was 0.24 0.06 (range, 0.16 to 0.34). Analysis showed no statistically signicant relationship between the serum sample collection times and the serum acyclovir levels (Pearson correlation coefcient, 0.51; P .14) or between the vitreous sample collection times and the vitreous acyclovir levels (Pearson correlation coefcient, 0.11; P .75). No serious adverse events were associated with the administration of oral valacyclovir. The drug was tolerated well by all participants with no reported side effects.

DISCUSSION
VALACYCLOVIR (VALTREX; GLAXOSMITHKLINE, RESEARCH

Triangle Park, North Carolina, USA) was approved by the Food and Drug Administration in 1995 for the treatment of herpes virus infections. Its current indications include herpes zoster (shingles), genital herpes simplex, and herpes labialis. The drug is the l-valyl ester of acyclovir and is converted rapidly to acyclovir after oral administration. Orally administered valacyclovir offers a distinct advantage over orally administered acyclovir because of its 684 AMERICAN JOURNAL
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greater bioavailability. In healthy individuals, the bioavailability of valacyclovir has been reported to be 54%, more than three times that of comparable doses of acyclovir.10 This increased bioavailability is believed to result from greater absorption of valacyclovir across the intestinal wall as compared with acyclovir. After being absorbed, valacyclovir is converted rapidly into acyclovir by valacyclovir hydrolase during rst-pass metabolism.11 The high bioavailability of valacyclovir leads to plasma acyclovir levels comparable with those obtained with intravenous administration of acyclovir. Weller and associates found that 1000 mg valacyclovir given four times daily resulted in acyclovir area under the concentrationtime curve values comparable with that of intravenous administration of acyclovir at doses of 5 mg/kg every eight hours.12 This was later conrmed by Hoglund and associates.13 Furthermore, plasma acyclovir levels comparable with intravenous doses of 10 mg/kg every eight hours can be achieved with higher valacyclovir doses of 2000 mg given four times daily.12 Hoglund and associates postulated that the lower peak plasma concentrations associated with oral therapy may reduce the risk of renal adverse events compared with intravenous acyclovir administration.13 Virus sensitivity testing has not been standardized, and the quantitative relationship between the in vitro susceptibility of herpes viruses to antiviral agents and the clinical response to treatment has not been established in humans.14 Published 50% inhibitory concentration (IC50) values of acyclovir for HSV-1, HSV-2, and VZV vary over a wide range, probably attributable to differences in the assays and laboratories used to derive them. Reported IC50 values for HSV-1 range from 0.02 to 13.5 g/ml, those for HSV-2 range from 0.01 to 9.9 g/ml, and those for VZV range from 0.12 to 10.8 g/ml.14,15 Given these values, valacyclovir has been shown to achieve serum levels within the inhibitory ranges for most strains of HSV-1, HSV-2, and VZV. Inhibitory acyclovir levels for most strains also are achieved in the cerebrospinal uid (CSF) after repeated doses of valacyclovir.16 The high end of the reported IC50 ranges likely represents relatively resistant virus strains that are encountered less commonly in the clinical setting. Although acyclovir levels in serum and CSF after administration of oral valacyclovir have been well described, little is known about the intraocular levels of acyclovir achieved with either intravenous acyclovir or orally administered valacyclovir. In 2002, Dias and associates reported a study of ocular penetration of intravenous acyclovir and intravenous valacyclovir in New Zealand albino rabbits.17 Although they were able detect acyclovir in the aqueous humor, they failed to detect measurable levels of the drug in the vitreous. To our knowledge, our study is the rst to measure vitreous acyclovir concentrations after either oral valacyclovir or intravenous acyclovir dosing. We found that the oral administration of valacyclovir quickly leads to substantial vitreous acyclovir concentrations in noninamed human eyes. The OPHTHALMOLOGY APRIL 2008

vitreous levels achieved were consistent among study subjects. As with serum concentrations, the mean vitreous levels were within but not above the reported IC50 ranges for HSV-1, HSV-2, and VZV, suggesting that certain strains may be resistant. On average, the vitreous acyclovir levels were approximately 25% of the serum levels. The serum acyclovir levels in our study were consistent with those previously reported for oral valacyclovir,12,13 and the fact that serum concentrations measured in the two sets of serum samples were nearly identical indicates a high level of precision of our HPLC assay. Our study is limited by the fact that vitreous levels were measured at a single time point. Our methodology therefore precludes any conclusions regarding steady-state vitreous levels of acyclovir during oral valacyclovir therapy. In addition, the treatment time required to achieve therapeutic levels and the duration of these levels cannot be determined from our data. The time to maximum serum concentration of acyclovir after an oral dose of valacyclovir has been reported to be approximately two hours.12 Our mean collection time for serum samples was somewhat greater than two hours, which may explain the slightly lower serum acyclovir concentrations in our study compared with previously reported maximum serum concentrations. The time to maximum vitreous acyclovir concentration has not been reported. It therefore is not known whether the vitreous acyclovir concentrations obtained in this study represent maximum vitreous concentrations after oral valacyclovir at

standard doses. The values obtained in this study may underestimate the maximum vitreous concentration of acyclovir because vitreous sampling may have occurred before or after the time to maximum vitreous concentration. No statistically signicant relationship between the serum and vitreous sample collection times and the serum and vitreous acyclovir levels was detected in our study, possibly because of the small patient sample size. Of note is the fact that our study was conducted in noninamed eyes, unlike those affected by ARN. One may postulate that vitreous acyclovir concentrations higher than those reported in our study may be achieved in eyes with ARN, because the blood-retina barrier is severely compromised in these eyes. The ndings of our study demonstrate that the oral administration of valacyclovir rapidly can result in potentially therapeutic concentrations of acyclovir in the vitreous for nonresistant strains of HSV-1, HSV-2, and VZV. These results, in conjunction with several recent clinical case series demonstrating the successful use of valacyclovir in the primary treatment of ARN, suggest that oral valacyclovir may be a reasonable alternative to intravenous acyclovir in the management of ARN. In selected cases, initial adjunctive therapy with intravitreal antiviral agents, higher doses of oral antiviral drugs, or both may be considered to achieve high vitreous drug concentrations rapidly. Further studies are needed to clarify the role and to determine the ideal dosing regimen for valacyclovir in the treatment of ARN.

THE AUTHORS INDICATE NO FINANCIAL SUPPORT OR FINANCIAL CONFLICT OF INTEREST. INVOLVED IN DESIGN AND conduct of study (T.H.H., M.W.J., G.M.C.); collection of data (T.H.H., M.W.J., G.M.C., D.N.F.); management of data (T.H.H., M.W.J., D.N.F.); analysis of the data (T.H.H., M.W.J., D.N.F.); interpretation of the data (T.H.H., M.W.J., G.M.C., D.N.F.); preparation of the manuscript (T.H.H., M.W.J., G.M.C., D.N.F.); review of the manuscript (T.H.H., M.W.J., G.M.C., D.N.F.); and approval of the manuscript (T.H.H., M.W.J., G.M.C., D.N.F.). Informed consent was obtained from all participants and the study was approved by the University of Michigan Institutional Review Board. The authors thank David C. Musch, PhD, Department of Ophthalmology and Visual Sciences, University of Michigan, Ann Arbor, Michigan for providing statistical consultation.

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