An Exclusively Oral Ribavirin Regimen for Respiratory Syncytial Virus Infection after Lung Transplantation is Effective and Cost-Efficient

PURPOSE: Respiratory Syncytial Virus (RSV) infection after lung transplantation (LTx) has been associated with acute and chronic allograft dysfunction. A previous study at our center demonstrated an IV loading regimen followed by oral therapy was an effective and cost-efficient treatment for RSV infection after LTx. This study evaluates efficacy, safety, and cost-efficiency of an entirely oral ribavirin regimen for treatment of RSV infection after LTx. METHODS: We performed a single center retrospective analysis of 49 consecutive LTx recipients from Aug-2016 to Aug-2019. RSV was diagnosed by PCR from nasopharyngeal swab or bronchoalveolar lavage fluid. Patients were followed for 3 months post RSV treatment. Data collected included longitudinal spirometry, hemoglobin and drug cost. RESULTS: Forty-nine patients (mean age 47±15, male:female ratio 25:24), presented with 52 episodes of clinically symptomatic RSV. Complete spirometry data was available for 33 episodes. Mean FEV1 fell from baseline 2.33±0.69 to 2.06±0.71 (p<0.001) at presentation. All patients received an oral loading dose of ribavirin (33mg/kg in 3 divided doses) followed by 20mg/kg orally in 2 divided doses from day 2 (adjusted for renal function). Median duration of therapy was 7 days (6-21). Patients also received prednisolone 1mg/kg/day weaned by 5mg second daily to usual baseline dose, and antibiotic cover. Adverse events included worsening anemia in 3/24 patients with existing anemia and new-onset anemia in 4/21. Mean hemoglobin fell from 121±20 to 117±19 (p=0.042). Two patients required a transfusion for anemia associated with prolonged ribavirin therapy. Mean FEV1 recovered to 2.20±0.76 after completion of therapy and to 2.26±0.74 within 3 months (p<0.001 compared to FEV1 at presentation). There were 3 deaths: one at 2 months post RSV (respiratory failure), and 2 late unrelated deaths. Compared to our center's previous regimen using IV ribavirin loading, mean drug cost reduced from US$1445 to US$60 per treatment course. Hospital ...