Remdesivir for COVID-19 Treatment: ACP Practice Points

Qaseen A, Yost J, Etxeandia-Ikobaltzeta I, et al., on behalf of the Scientific Medical Policy Committee of the American College of Physicians.
Should Remdesivir Be Used for the Treatment of Patients With COVID-19? Rapid, Living Practice Points From the American College of Physicians (Version 2). Ann Intern Med 2021;Feb 9:[Epub ahead of print].

This second version of a guidelines document by the Scientific Medical Policy Committee of the American College of Physicians (ACP) based on an updated systematic review provides evidence-based recommendations surrounding the use of remdesivir in the treatment of coronavirus disease 2019 (COVID-19). The following are 10 key points to remember summarizing the data and guidelines:

  1. There are five clinical trials assessing the effectiveness of remdesivir in the treatment of COVID-19, encompassing a total of 7,797 hospitalized patients.
  2. In this update, severity of disease is now defined by respiratory support requirements (no requirement, supplemental oxygen, or mechanical ventilation) rather than classifications such as “moderate or severe.”
  3. This second version incorporates findings from one new clinical trial published and the final findings of a prior study, both assessing the effectiveness of a 10-day remdesivir course compared to standard of care and placebo.
  4. The most recent data find little to no effect of a 10-day course of remdesivir on mortality or need for mechanical ventilation. Treatment with remdesivir remained associated with clinical improvement, length of stay, and a reduction in serious adverse events.
  5. There is insufficient evidence to advise against or for considering the use of remdesivir in patients who do not require supplemental oxygen at the time of drug initiation.
  6. Practice Point 1: A 5-day treatment of remdesivir in hospitalized patients with COVID-19 who do not require mechanical ventilation or extracorporeal membrane oxygenation (ECMO) should be considered; with no evidence of harm, and evidence for a slight reduction in mortality, moderate increase in recovery, and slight reduction in the need for mechanical ventilation.
  7. Practice Point 2: In post hoc analyses, treatment beyond 5 days in patients who progressed to requiring mechanical ventilation or ECMO was associated with lower mortality; thus, extending treatment to 10 days in patients who have not had adverse effects should be considered.
  8. Practice Point 3: Treatment with remdesivir should be avoided in patients with COVID-19 already on mechanical ventilation or ECMO, as a 10-day course of remdesivir in this patient population was associated with a modest increase in mortality.
  9. Significant evidence gaps remain regarding the optimal duration of treatment with remdesivir, the impact of disease severity, and duration of symptoms at the time of initiation of remdesivir.
  10. The ACP recommendations differ from the World Health Organization (WHO) guidelines, which advise against the use of remdesivir for the following reasons: they are based on different systematic reviews, the WHO guideline considered the effect of remdesivir regardless of its duration of use and did not make a recommendation based on disease severity, judging the credibility of the evidence to be insufficient to make a recommendation.

Clinical Topics: COVID-19 Hub, Prevention

Keywords: Coronavirus, Coronavirus Infections, COVID-19, Extracorporeal Membrane Oxygenation, Iatrogenic Disease, Length of Stay, Primary Prevention, remdesivir, Respiration, Artificial, Respiratory Insufficiency, Severity of Illness Index, Standard of Care, Ventilation

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