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Potential Therapeutic Agents
Remdesivir

Remdesivir

Notes

  • Remdesivir reduced the time to recovery by 29% compared with placebo (10 v 15 days) among patients with COVID-19 infection.
  • Remdesivir appears to have the most benefit in patients who have low-flow oxygen requirements and has no benefit for individuals who are mechanically ventilated >48 hours.

  • On October 22, 2020, the FDA approved remdesivir for use in adults and pediatric patients (≥ 12 years and weighing at least 40 kg) with COVID-19 requiring hospitalization

  • The Emergency Use Authorization granted on May 1, 2020 is still in effect for pediatric patients (< 12 years old and weighing at least 3.5 kg)

Availability

At this time, we recommend remdesivir for patients meeting the below criteria:

  • Positive SARS-CoV-2 RT-PCR result within a week of admission

  • Symptom onset within 14 days prior to initiation of treatment

  • Hypoxia defined as:

    • SpO₂ ≤94% on room air OR
    • Requiring supplemental oxygen (low-flow/highflow) OR
    • Mechanically ventilated <48 hours

  • ALT < 400 (10x ULN) prior to initiation

Patients who are not hypoxic but high risk (anticipatory chemotherapy, lung transplant) may be considered on a case by case basis. Patients representing the Essential Critical Workforce, as defined by California Executive Order N-33-20, could be considered for higher prioritization.

If remdesivir is given via EUA (for pediatrics < 12 years or weighing 3.5-40kg), a patient fact sheet must be reviewed with the patient/caregiver prior to use.

If supply becomes severely limited (i.e. when demand > supply), those with terminal illness will not be considered. Modifiers for the definition of terminal illness considered include:

  • Clinical Frailty Score ≥8
  • Advanced progressive incurable neurologic disease requiring ventilatory support or Rankin scale ≥5
  • Metastatic cancer with expected survival ≤1 year despite treatment

Dosing

  • 200mg IV x1, followed by 100mg q24h for duration of hospitalization

  • 5 days recommended

Patients Weighing 3.5kg - <40kg

  • Loading dose: 5 mg/kg/dose IV x1 dose (Max: 200mg)

  • Maintenance dose: 2.5 mg/kg/dose IV Q24H (Max: 100mg)

  • 5 days recommended

Patients Weighing 40kg or Higher

  • 200mg IV x1, followed by 100mg Q24H for duration of hospitalization

  • 5 days recommended

Duration: Data suggest that a 5-day course is non-inferior to a 10-day course, and as such we recommend universal 5-day courses. Any longer courses of remdesivir require an ID consult.

Monitoring

  • Self-limiting, reversible hepatotoxicity has been observed, which resolved after therapy cessation.

  • Nephrotoxicity has been observed in preclinical studies.