Are there instances when you use letermovir without the addition of acyclovir when managing a kidney transplant recipient for CMV prophylaxis?

I am assuming this question is about initial viral prophylaxis after transplant and exposure to induction immunosuppression. We have not used often letermovir as first line CMV prophylaxis outside of a research study, or during valcyte shortages. Cases where one might consider Letermovir as prophylaxis would be significant leukopenia prior to transplant given the impact of Valcyte on WBC. If the patient has a history of ganciclovir resistance, in the past, I would consult transplant infectious d...

Letermovir is approved as primary CMV prophylaxis in transplant recipients. However, our first line is still valganciclovir. Adding aciclovir if using letermovir is prudent to protect against VZV/HSV. Cost may be an issue as this drug is much more expensive than valgancilocvir.

I have personally only used this drug in treatment of resistant CMV disease.

Letermovir is also a CYP3A4 inhibitor and close monitoring of CNI levels is necessary.

We have switched to letermovir+acyclovir as first line prophylaxis for high-risk CMV. This was done given the significantly better toxicity profile of letermovir as compared to valganciclovir, in particular marrow toxicity, and clinical non-inferiority. For patients in whom insurance coverage will not cover letermovir or with high copays, we will still use valganciclovir.